CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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 930 563.75 20858.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 424 424.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 50 31.75 1138.75 35.87
TCM-T1017TL-TARGETED CASE MANAGEMENT 1603 6255.50 231435.00 37.00
Subtotal (Total Children Is Unduplicated) 1639 7275.00 253432.50 34.84
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.00 48.50 48.50
EVAL-EVAL-DEVELOPMENTAL EVALUATION 52 51.75 2587.50 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 43 34.75 1737.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 5.50 412.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.50 37.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 6.50 487.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 36 46.50 3487.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 29 29.00 1609.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 84 58.50 4387.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 4.00 300.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 79 63.50 4762.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 244 241.00 13375.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 193 216.00 16200.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 155 155.00 28530.50 184.07
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 6 6.00 1650.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 34 34.00 3570.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 23 23.00 1115.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 13 13.00 630.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 31 31.00 1503.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.00 388.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 68 69.00 3346.50 48.50
Subtotal (Total Children Is Unduplicated) 542 1098.50 90328.00 82.23
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 51 85.25 4262.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 105 219.00 10950.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 87 202.00 5050.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 36 71.00 3550.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 39 80.00 2000.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 4.00 200.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 63 133.00 6650.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 58 120.00 3000.00 25.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 5 2.50 183.55 73.42
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 108 3232.00 80800.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 66 1987.00 49675.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 41.00 2050.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 570 4617.25 230812.50 49.99
OCCT-97530-OT SESSION BY LICENSED OT 109 480.75 32633.31 67.88
OCCT-97530HM-OT SESSION BY OT ASST 7 13.50 733.32 54.32
PHY-97110-PT SESSION BY LICENSED PT 115 495.75 33651.51 67.88
PHY-97110HM-PT SESSION BY PT ASST 3 7.00 380.24 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 131 598.15 40546.90 67.79
SPL-92508-GROUP SPL SESSION PER CHILD 3 4.50 59.40 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 357 373.00 2517.50 6.75
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 573 118770 59385.00 0.50
Subtotal (Total Children Is Unduplicated) 1001 131538 569140.73 4.33
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Total 139911.15 912901.23 6.52
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Number of Children (Unduplicated) With at Least One Service 1716
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Center 04
Flag Claims Units Chgs Paid
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R 22 48.50 1794.50 0.00
U 0 0.00 0.00 0.00
B 4206 4047.25 151038.75 0.00
P 3407 121613.03 224627.93 224654.41
D 69 420.50 5068.06 2509.14
S 0 0.00 0.00 0.00
H 1010 3310.87 169474.16 169951.08
T 0 0.00 0.00 0.00
6755 10471.00 360897.83 0.00
Other 0 0.00 0.00 0.00
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Total 15469 139911.15 912901.23 397114.63