CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
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 684 389.75 14420.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 340 340.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 40 28.00 1036.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1521 5978.00 221186.00 37.00
Subtotal (Total Children Is Unduplicated) 1546 6735.75 236642.75 35.13
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 45 43.50 2175.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 56 55.00 2750.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 6.50 487.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 1.50 112.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 4.50 337.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 25 25.00 1875.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 29 27.00 1498.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 66 37.50 2812.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 2.50 187.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 87 68.50 5137.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 201 187.50 10406.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 137 140.50 10537.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 101 101.00 18685.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.00 1100.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 27 27.00 2835.00 105.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 14 14.00 679.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 21 21.00 1018.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 14 14.00 679.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.00 436.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 52 52.00 2522.00 48.50
Subtotal (Total Children Is Unduplicated) 465 841.50 66272.25 78.75
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 26 30.25 1512.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 48 121.00 6050.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 28 73.00 1825.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 14 31.00 1550.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 10 27.00 675.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 5.00 250.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 36 82.00 4100.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 19 46.00 1150.00 25.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 86 2584.00 64600.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 47 1570.00 39250.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 666 5908.00 295400.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 142 790.99 53692.67 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 4.50 244.44 54.32
PHY-97110-PT SESSION BY LICENSED PT 95 436.50 29629.62 67.88
PHY-97110HM-PT SESSION BY PT ASST 5 20.00 1086.40 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 13.00 650.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 182 888.73 60225.17 67.77
SPL-92508-GROUP SPL SESSION PER CHILD 2 4.00 52.80 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 286 286.00 2288.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 665 150009 75004.50 0.50
Subtotal (Total Children Is Unduplicated) 1009 162930 639236.10 3.92
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Total 170507.22 942151.10 5.53
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Number of Children (Unduplicated) With at Least One Service 1639
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Center 04
Flag Claims Units Chgs Paid
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R 25 21.50 795.50 0.00
U 0 0.00 0.00 0.00
B 1805 1815.50 74542.00 0.00
P 5538 154839.62 337537.87 335129.87
D 102 660.25 4733.11 2546.51
S 0 0.00 0.00 0.00
H 1403 4664.10 238408.95 238527.33
T 0 0.00 0.00 0.00
5490 8506.25 286133.67 450.00
Other 0 0.00 0.00 0.00
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Total 14363 170507.22 942151.10 576653.71