CMS/EIP Fiscal Report Center: 05
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 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 374 1143.75 42263.25 36.95
Subtotal (Total Children Is Unduplicated) 674 1896.50 59866.00 31.57
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Screening, Eval, and Assessment,Class #02
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 1 1.00 75.00 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 6 8.19 462.90 56.52
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 5.86 329.18 56.17
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 41.00 2275.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 20.50 1537.50 75.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 3.25 61.00 18.77
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 65 108.55 6256.83 57.64
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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 220 168.00 8400.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 11 4.25 106.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 39 16.50 825.00 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 167 792.24 30723.49 38.78
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 132 662.69 33024.07 49.83
INTR-INTR-INTERPRETER 7 44.75 2237.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 14 32.61 1953.58 59.91
PHY-97110-PT SESSION BY LICENSED PT 12 27.61 1664.69 60.29
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 58 187.62 12106.12 64.52
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 5.00 271.60 54.32
TRAN-TRAN-FAMILY TRANSPORTATION 1 12.00 229.62 19.14
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 400 87448.0 43724.00 0.50
Subtotal (Total Children Is Unduplicated) 431 89566.8 143228.42 1.60
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Total 91571.82 209351.25 2.29
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Number of Children (Unduplicated) With at Least One Service 730
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Center 05
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 3259 89025.20 146757.89 146757.89
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
3330 2546.62 62593.36 0.00
Other 0 0.00 0.00 0.00
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Total 6589 91571.82 209351.25 146757.89