CMS/EIP Fiscal Report Center: 57
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 201 124.50 4606.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 527 534.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 333 279.00 10323.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1211 4488.75 165972.75 36.98
TCON-TCON-TRANSITION CONFERENCE 93 93.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1247 5519.25 180902.25 32.78
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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 21 25.50 1912.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.50 187.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 24 32.00 1776.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 283 334.50 25087.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 342 439.00 24364.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 50 60.00 4500.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 33 34.00 1649.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 12 12.00 582.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 15 15.00 727.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 25 25.00 1212.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 117 119.00 5771.50 48.50
VISD-VISD-VISION EVALUATION DIAGNOSTIC 1 40.00 20.00 0.50
Subtotal (Total Children Is Unduplicated) 547 1193.50 70600.50 59.15
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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 427 828.25 41237.50 49.79
CONIP-CONIP-CONSULT, ITDS, PHONE 235 422.00 10550.00 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 408 797.25 37832.50 47.45
CONSP-CONSP-CONSULT, SLP, PHONE 224 427.00 10675.00 25.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 10 48.00 1540.00 32.08
ECE-ECE-EARLY CHILDHOOD EDUCATION 88 14175.0 132752.00 9.37
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 676 5901.75 289147.50 48.99
OCCT-97530-OT SESSION BY LICENSED OT 120 557.00 37809.16 67.88
OCCT-97530HM-OT SESSION BY OT ASST 4 18.50 407.32 22.02
PHY-97110-PT SESSION BY LICENSED PT 134 625.25 42408.03 67.83
PHY-97110HM-PT SESSION BY PT ASST 4 12.50 502.36 40.19
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 3.00 150.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 294 1195.00 81116.60 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 11 41.00 654.30 15.96
TRAN-TRAN-FAMILY TRANSPORTATION 31 1482.00 19852.00 13.40
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 732 145883 74882.58 0.51
Subtotal (Total Children Is Unduplicated) 931 172523 787811.85 4.57
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Total 179236.00 1039314.60 5.80
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Number of Children (Unduplicated) With at Least One Service 1422
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Center 57
Flag Claims Units Chgs Paid
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R 259 269.00 10553.50 0.00
U 0 0.00 0.00 0.00
B 385 397.00 17102.50 0.00
P 1354 1465.50 57589.00 57607.50
D 93 97.75 3804.75 0.00
S 207 3775.00 16567.38 16567.38
H 0 0.00 0.00 0.00
T 5836 148105.50 382954.56 383465.70
6269 24864.75 547166.63 162192.59
Other 42 261.50 3576.28 3678.09
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Total 14445 179236.00 1039314.60 623511.26