CMS/EIP Fiscal Report Center: 04
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 729 434.00 16058.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 460 460.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 37 27.25 1008.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1632 6414.75 237345.75 37.00
Subtotal (Total Children Is Unduplicated) 1649 7336.00 254412.00 34.68
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.00 48.50 48.50
EVAL-EVAL-DEVELOPMENTAL EVALUATION 63 60.50 3025.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 50 48.50 2425.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 4.50 337.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 5.50 412.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 12 11.00 825.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 47 56.50 4237.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 42 41.00 2275.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 96 60.00 4500.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 0.50 37.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 77 56.00 4200.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 257 239.00 13264.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 191 182.00 13650.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 135.00 135.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 149 149.00 27565.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.00 1100.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 52 52.00 5460.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 3 3.00 480.00 160.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 8 8.00 388.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 18 18.00 873.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 12 12.00 582.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 10 10.00 485.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 35 35.00 1697.50 48.50
Subtotal (Total Children Is Unduplicated) 555 1058.00 88004.00 83.18
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 22 32.25 1612.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 76 148.00 7400.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 39 76.00 1900.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 22 38.00 1900.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 15 29.00 725.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 10.50 525.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 61 102.00 5100.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 25 47.00 1175.00 25.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 84 2722.00 68050.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 48 1915.00 47875.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 574 3819.75 190987.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 132 631.50 42866.22 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 1.50 81.48 54.32
PHY-97110-PT SESSION BY LICENSED PT 102 484.70 32904.10 67.89
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 4 6.00 300.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 158 783.64 53193.49 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.00 26.40 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 349 353.00 2824.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 586 107379 53689.50 0.50
Subtotal (Total Children Is Unduplicated) 1002 118581 513135.19 4.33
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Total 126974.84 855551.19 6.74
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Number of Children (Unduplicated) With at Least One Service 1710
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Center 04
Flag Claims Units Chgs Paid
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R 2 2.00 87.00 0.00
U 0 0.00 0.00 0.00
B 3421 3396.00 133991.00 0.00
P 3677 110847.52 231046.51 231198.08
D 11 133.00 1166.98 1187.32
S 0 0.00 0.00 0.00
H 836 2624.82 136387.76 136630.12
T 0 0.00 0.00 0.00
6098 9971.50 352871.94 0.00
Other 0 0.00 0.00 0.00
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Total 14045 126974.84 855551.19 369015.52