CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:GR
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 312 204.00 7548.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 523 660.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 306 379.25 12572.25 33.15
TCM-T1017TL-TARGETED CASE MANAGEMENT 653 2529.75 93582.25 36.99
TCON-TCON-TRANSITION CONFERENCE 65 65.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1018 3838.00 113702.50 29.63
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 7 7.00 350.00 50.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.00 50.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 45 45.00 2250.00 50.00
FANE-FANE-FAMILY INTERVIEW BY COMMUNITY PROVIDER 4 5.00 150.00 30.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 5.00 277.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 130 131.00 9825.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 165 165.00 9157.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 33.00 2475.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 16 16.00 776.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 7 7.00 339.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.00 416.50 46.28
SCREEN-T1023-INTERDISCIPLINARY SCREENING 7 8.00 400.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 61 61.00 2958.50 48.50
Subtotal (Total Children Is Unduplicated) 292 498.00 29747.50 59.73
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 9.25 462.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 308 598.50 29762.50 49.73
CONIP-CONIP-CONSULT, ITDS, PHONE 258 519.75 12981.25 24.98
CONOF-CONOF-CONSULT, OT, FACE TO FACE 10 16.00 800.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 7 7.25 362.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 6 8.25 206.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 296 575.00 28750.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 255 520.50 13012.50 25.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 9 58.00 2030.00 35.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 40.00 720.00 18.00
EIIF-90801-PSYCHIATRIC DIAG INTERVIEW 1 8.00 400.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 372 3170.25 158137.50 49.88
OCCT-97530-OT SESSION BY LICENSED OT 22 105.00 7127.40 67.88
PHY-97110-PT SESSION BY LICENSED PT 41 159.75 10695.31 66.95
SHIN-EIIF_NM-INITIAL SHINE SERVICES, IND NONMED 1 1.00 50.00 50.00
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 2.00 100.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 113 476.75 32116.19 67.36
TRAN-TRAN-FAMILY TRANSPORTATION 2 135.00 121.50 0.90
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 671 141526 71200.30 0.50
Subtotal (Total Children Is Unduplicated) 748 147937 369041.95 2.49
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Total 152272.50 512491.95 3.37
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Number of Children (Unduplicated) With at Least One Service 1261
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Center 57
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 229 5276.50 13545.14 13545.14
H 0 0.00 0.00 0.00
T 5561 142651.75 361686.06 362929.06
4330 4344.25 137260.75 202.50
Other 0 0.00 0.00 0.00
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Total 10120 152272.50 512491.95 376676.70