CMS/EIP Fiscal Report Center: 52
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 403 213.25 7890.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 362 434.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 325 250.25 9250.00 36.96
TCM-T1017TL-TARGETED CASE MANAGEMENT 386 1042.50 38396.75 36.83
TCON-TCON-TRANSITION CONFERENCE 89 89.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 703 2029.00 55537.00 27.37
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 7 10.50 525.00 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 3 3.00 150.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 48.50 48.50
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.00 166.50 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 33 33.00 1650.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 18.50 1308.00 70.70
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.00 198.50 66.17
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 13.50 906.50 67.15
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 40.50 2247.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.50 337.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 9 9.00 436.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 11 11.00 533.50 48.50
Subtotal (Total Children Is Unduplicated) 94 155.50 8830.25 56.79
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 56 61.50 3075.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 10 11.25 562.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.25 6.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 3 3.50 175.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 3.50 175.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 4 1.75 43.75 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 9 11.25 562.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 0.50 12.50 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 59 310.01 15500.03 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 5.00 250.00 50.00
INTR-INTR-INTERPRETER 1 2.75 137.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 26 182.17 12365.08 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 4.50 244.44 54.32
PHY-97110-PT SESSION BY LICENSED PT 37 182.41 12371.72 67.82
PHY-97110HM-PT SESSION BY PT ASST 1 2.50 135.80 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 3.50 175.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 96 509.89 34611.04 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 521 117463 58730.00 0.50
Subtotal (Total Children Is Unduplicated) 545 118759 139133.11 1.17
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Total 120943.73 203500.36 1.68
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Number of Children (Unduplicated) With at Least One Service 777
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Center 52
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 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 2 2.50 133.25 0.00
T 23 1205.00 1442.68 1504.68
6010 119736.23 201924.43 0.00
Other 0 0.00 0.00 0.00
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Total 6035 120943.73 203500.36 1504.68