CMS/EIP Fiscal Report Center: 57
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 248 155.50 5753.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 496 504.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 358 301.25 11146.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1324 5056.25 186822.25 36.95
TCON-TCON-TRANSITION CONFERENCE 62 62.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1346 6079.00 203722.00 33.51
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Screening, Eval, and Assessment,Class #02
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 60.00 60.00
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 8 12.00 540.00 45.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 8 10.00 500.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 66 66.00 3300.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 7.50 562.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 13.50 749.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 244 314.50 23587.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 263 409.50 22671.75 55.36
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 22.00 1650.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 9 9.00 436.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 28 28.00 1358.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 11 11.00 533.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 26 26.00 1261.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 117 118.00 5674.50 48.09
VISD-VISD-VISION EVALUATION DIAGNOSTIC 1 60.00 30.00 0.50
Subtotal (Total Children Is Unduplicated) 481 1109.50 63027.00 56.81
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 5.75 287.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 491 1044.50 52200.00 49.98
CONIP-CONIP-CONSULT, ITDS, PHONE 166 303.50 7587.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 6 10.00 500.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 11 20.00 1000.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 3 4.00 100.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 479 1005.00 50200.00 49.95
CONSP-CONSP-CONSULT, SLP, PHONE 166 300.50 7512.50 25.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 11 39.50 1435.00 36.33
ECE-ECE-EARLY CHILDHOOD EDUCATION 68 8235.00 74115.00 9.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 11.50 315.00 27.39
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 13 46.00 2300.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 711 6325.00 316200.00 49.99
OCCT-97530-OT SESSION BY LICENSED OT 120 488.75 33176.35 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 3.50 237.58 67.88
PHY-97110-PT SESSION BY LICENSED PT 133 582.25 39319.49 67.53
PHY-97110HM-PT SESSION BY PT ASST 1 2.50 135.80 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 2.00 100.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 380 1674.75 112911.61 67.42
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 4.00 135.76 33.94
SPL-92508-GROUP SPL SESSION PER CHILD 7 18.00 237.60 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 763 157800 81130.59 0.51
Subtotal (Total Children Is Unduplicated) 987 177926 781137.28 4.39
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Total 185114.50 1047886.28 5.66
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Number of Children (Unduplicated) With at Least One Service 1528
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Center 57
Flag Claims Units Chgs Paid
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R 118 149.50 5701.00 0.00
U 0 0.00 0.00 0.00
B 466 538.00 22361.25 0.00
P 1850 1972.25 78609.00 78609.00
D 62 62.75 2858.00 0.00
S 29 708.50 1643.96 1643.96
H 0 0.00 0.00 0.00
T 6765 162452.50 450402.90 450764.22
6172 18773.50 482230.51 210960.95
Other 54 457.50 4079.66 4216.36
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Total 15516 185114.50 1047886.28 746194.49