CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 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 577 2200.25 81409.25 37.00
Subtotal (Total Children Is Unduplicated) 1247 3121.50 98475.50 31.55
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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 4 2.50 187.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 6.00 450.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 42 37.00 2775.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 13 11.00 610.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 21.50 1612.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 32 23.50 1762.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 79 78.00 4329.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 163 136.00 10200.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 13 13.00 2405.00 185.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 16 16.00 776.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 25 25.00 1212.50 48.50
Subtotal (Total Children Is Unduplicated) 409 492.50 32476.00 65.94
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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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 190 1147.75 57387.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 64 255.00 17309.40 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 1.50 81.48 54.32
PHY-97110-PT SESSION BY LICENSED PT 24 125.47 8516.83 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 3.00 150.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 70 394.80 26799.03 67.88
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) 865 110142 187095.24 1.70
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Total 113756.27 318046.74 2.80
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Number of Children (Unduplicated) With at Least One Service 1467
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Center 04
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 2475 109673.27 183832.24 183833.51
D 11 133.00 1166.98 1187.32
S 0 0.00 0.00 0.00
H 11 32.00 1671.52 1671.52
T 0 0.00 0.00 0.00
5084 3918.00 131376.00 0.00
Other 0 0.00 0.00 0.00
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Total 7581 113756.27 318046.74 186692.35