CMS/EIP Fiscal Report Center: 57
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
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 187 119.25 4412.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 474 481.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 303 257.75 9536.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 656 2450.75 90677.75 37.00
TCON-TCON-TRANSITION CONFERENCE 93 93.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 968 3401.75 104626.75 30.76
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Screening, Eval, and Assessment,Class #02
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.00 60.00 60.00
BEHV-90801-PSYCHIATRIC DIAG INTERVIEW 1 1.00 50.00 50.00
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 6 6.00 300.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 47 47.00 2400.00 51.06
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 6.50 487.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.50 416.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 138 168.00 12600.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 168 220.00 12210.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 27 31.00 2325.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 18 18.00 873.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.00 339.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 11 11.00 533.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 87 87.00 4219.50 48.50
VISD-VISD-VISION EVALUATION DIAGNOSTIC 1 40.00 20.00 0.50
Subtotal (Total Children Is Unduplicated) 318 655.00 37028.25 56.53
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 6.00 3125.00 520.83
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.75 137.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 425 824.25 41037.50 49.79
CONIP-CONIP-CONSULT, ITDS, PHONE 234 420.00 10500.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 8 14.00 662.50 47.32
CONOP-CONOP-CONSULT, OT, PHONE 1 1.00 25.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 11 15.00 750.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 4 9.00 225.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 406 792.25 37582.50 47.44
CONSP-CONSP-CONSULT, SLP, PHONE 224 426.00 10650.00 25.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 10 48.00 1540.00 32.08
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 2 34.00 720.00 21.18
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 21.00 450.00 21.43
EIIF-90801-PSYCHIATRIC DIAG INTERVIEW 1 4.00 200.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 382 3257.75 156947.50 48.18
OCCT-97530-OT SESSION BY LICENSED OT 22 62.50 4242.50 67.88
PHY-97110-PT SESSION BY LICENSED PT 39 133.50 9028.04 67.63
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 3.00 150.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 158 548.00 37198.24 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 3 2.50 33.00 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 8 214.00 1840.00 8.60
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 706 144641 74029.58 0.51
Subtotal (Total Children Is Unduplicated) 808 151480 391073.86 2.58
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Total 155536.25 532728.86 3.43
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Number of Children (Unduplicated) With at Least One Service 1220
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Center 57
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 1 1.25 46.25 64.75
D 79 80.00 3054.00 0.00
S 203 3651.50 16305.56 16305.56
H 0 0.00 0.00 0.00
T 5816 147801.25 379225.29 379787.34
3981 3999.75 133947.44 732.44
Other 2 2.50 150.32 150.31
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Total 10082 155536.25 532728.86 397040.40