CMS/EIP Fiscal Report Center: 05
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 289 129.25 4782.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 276 277.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 365 346.50 12820.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 768 2490.50 92093.00 36.98
Subtotal (Total Children Is Unduplicated) 773 3243.25 109695.75 33.82
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 125.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 8 8.00 400.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 9 13.25 662.50 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 2 2.00 111.00 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.00 150.00 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 7 7.00 525.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 10 11.50 638.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 40 52.19 3762.90 72.10
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 9.00 675.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 37 46.36 3366.68 72.62
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 34 54.00 2997.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 28.00 2100.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 16 16.00 1164.48 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 9 9.00 451.35 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 14.00 679.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 6.00 291.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 6.25 206.50 33.04
SCREEN-T1023-INTERDISCIPLINARY SCREENING 10 10.00 500.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 14 14.00 679.00 48.50
Subtotal (Total Children Is Unduplicated) 161 319.55 20135.66 63.01
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 65 61.75 3087.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 4 3.00 75.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 221 168.75 8437.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 11 4.25 106.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 40 17.00 850.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 65 27.25 1362.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 94 64.00 3200.00 50.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 6 9.50 237.50 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 169 802.49 31235.99 38.92
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 233 978.94 48836.57 49.89
INTR-INTR-INTERPRETER 7 44.75 2237.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 97 291.36 19517.53 66.99
OCCT-97530HM-OT SESSION BY OT ASST 2 2.50 135.80 54.32
PHY-97110-PT SESSION BY LICENSED PT 144 523.86 35350.14 67.48
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 27.16 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 219 796.87 53462.01 67.09
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 12.50 679.00 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 8 23.75 313.50 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 1 12.00 229.62 19.14
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 400 87587.0 43793.50 0.50
Subtotal (Total Children Is Unduplicated) 459 91432.0 253174.57 2.77
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Total 94994.82 383005.98 4.03
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Number of Children (Unduplicated) With at Least One Service 783
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Center 05
Flag Claims Units Chgs Paid
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R 58 35.50 1313.50 0.00
U 0 0.00 0.00 0.00
B 2278 1246.00 46838.06 0.00
P 3284 89182.70 147877.39 147877.39
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
6306 4530.62 186977.03 0.00
Other 0 0.00 0.00 0.00
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Total 11926 94994.82 383005.98 147877.39