CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
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 783 363.50 13449.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 685 706.75 26149.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2320 6660.25 246403.50 37.00
TCON-TCON-TRANSITION CONFERENCE 1 1.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 2383 7731.50 286002.75 36.99
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.00 50.00 25.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 8 17.50 875.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 46 71.50 3575.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 19.50 1474.86 75.63
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.00 450.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 9.00 675.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 22.50 1237.75 55.01
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 197 272.00 20287.50 74.59
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 16.50 1076.50 65.24
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 63 105.50 7875.00 74.64
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 236 331.00 18370.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 163 209.50 15712.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 33.50 33.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 82.00 41.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 9.00 466.11 51.79
Subtotal (Total Children Is Unduplicated) 503 1096.50 72338.22 65.97
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 10 30.00 9584.02 319.47
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 43 66.75 2942.30 44.08
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 7 2.00 50.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 6 5.75 287.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 3 1.00 25.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.00 50.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 6.00 300.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 23 32.50 1625.00 50.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 5 40.00 300.00 7.50
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 36 719.00 7975.00 11.09
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 8 41.00 2050.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 26 115.75 5787.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 292 1534.75 76737.50 50.00
INTR-INTR-INTERPRETER 43 285.75 8692.50 30.42
OCCT-97530-OT SESSION BY LICENSED OT 67 278.25 19026.84 68.38
OCCT-97530HM-OT SESSION BY OT ASST 6 14.00 767.26 54.80
PHY-97110-PT SESSION BY LICENSED PT 103 474.75 32349.29 68.14
PHY-97110HM-PT SESSION BY PT ASST 2 7.00 380.24 54.32
RSPT-RSPT-RESPITE 1 53.00 424.00 8.00
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 457 2428.00 158894.31 65.44
SPL-92508-GROUP SPL SESSION PER CHILD 20 149.25 944.51 6.33
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 999 194586 103383.66 0.53
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 7 79.00 3950.00 50.00
Subtotal (Total Children Is Unduplicated) 1134 200956 436782.68 2.17
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Total 209783.75 795123.65 3.79
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Number of Children (Unduplicated) With at Least One Service 2517
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Center 01
Flag Claims Units Chgs Paid
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R 8 5.00 185.00 0.00
U 0 0.00 0.00 0.00
B 3248 2380.75 88838.25 0.00
P 9726 192917.25 380572.89 380572.84
D 9 6.25 321.25 0.00
S 1316 1034.50 38276.50 0.00
H 0 0.00 0.00 0.00
T 1 1.25 46.25 0.00
7685 13014.50 260508.37 0.00
Other 359 424.25 26375.14 0.00
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Total 22352 209783.75 795123.65 380572.84