CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Payclass Filters:GR
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 698 2527.00 93499.00 37.00
Subtotal (Total Children Is Unduplicated) 1345 3426.25 111157.25 32.44
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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 3 2.00 150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 23 21.00 1575.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 5.00 277.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 39 22.00 1650.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 1.50 112.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 30 23.50 1762.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 78 75.00 4162.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 138 126.00 9450.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 6.00 1110.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 7 7.00 339.50 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 7 7.00 339.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 29 29.00 1406.50 48.50
Subtotal (Total Children Is Unduplicated) 358 449.00 28665.00 63.84
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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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 213 1784.00 89200.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 77 335.14 22749.57 67.88
PHY-97110-PT SESSION BY LICENSED PT 29 135.50 9197.74 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 11.00 550.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 88 462.23 31274.35 67.66
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) 947 154428 248428.16 1.61
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Total 158303.37 388250.41 2.45
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Number of Children (Unduplicated) With at Least One Service 1590
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Center 04
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 3211 153413.62 244790.44 244790.50
D 108 662.75 4659.31 1995.31
S 0 0.00 0.00 0.00
H 18 158.50 2581.16 2547.25
T 0 0.00 0.00 0.00
5440 4068.50 136219.50 0.00
Other 0 0.00 0.00 0.00
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Total 8777 158303.37 388250.41 249333.06