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: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 776 446.00 16502.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 422 422.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 46 31.25 1156.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1733 6812.75 252071.75 37.00
Subtotal (Total Children Is Unduplicated) 1759 7712.00 269730.00 34.98
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 50 47.00 2350.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 56 55.00 2750.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 8.00 600.00 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 9 7.00 525.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 27 28.00 2100.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 32 30.00 1665.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 97 56.00 4200.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 6.00 450.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 104 78.00 5850.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 261 239.50 13292.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 170 171.50 12862.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 122 122.00 22570.00 185.00
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 22 22.00 1067.00 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) 550 991.50 78645.75 79.32
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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 49 122.00 6100.00 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 37 83.00 4150.00 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 671 5940.00 297000.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 143 794.49 53930.25 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 347 347.00 2776.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 670 150936 75468.00 0.50
Subtotal (Total Children Is Unduplicated) 1073 163955 642125.18 3.92
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Total 172658.97 990500.93 5.74
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Number of Children (Unduplicated) With at Least One Service 1852
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Center 04
Flag Claims Units Chgs Paid
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R 30 27.00 999.00 0.00
U 0 0.00 0.00 0.00
B 2043 2058.75 85576.25 0.00
P 5791 156061.37 350026.82 346812.60
D 112 673.75 5232.61 2565.01
S 0 0.00 0.00 0.00
H 1411 4688.10 239626.83 239745.21
T 0 0.00 0.00 0.00
6349 9150.00 309039.42 450.00
Other 0 0.00 0.00 0.00
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Total 15736 172658.97 990500.93 589572.82