CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 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 683 399.00 14763.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 349 349.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 45 31.75 1174.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1498 6081.75 225024.75 37.00
Subtotal (Total Children Is Unduplicated) 1521 6861.50 240962.50 35.12
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 48 46.00 2300.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 52 48.50 2425.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 10.50 787.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 5.50 412.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 43 43.00 3225.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 47 45.50 2525.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 36.50 2737.50 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 62 47.00 3525.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 183 156.50 8685.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 142 132.00 9900.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 109 109.00 20165.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.00 550.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 35 35.00 3675.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 11 11.00 533.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 31 31.00 1503.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 30 41.00 1988.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 83 84.00 4074.00 48.50
Subtotal (Total Children Is Unduplicated) 487 894.50 69779.50 78.01
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 40 42.50 2125.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 23 45.50 2275.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 18 33.00 825.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 6 13.00 650.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 7 14.00 350.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.00 50.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 17 29.50 1475.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 12 18.00 450.00 25.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 101 4573.00 114325.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 64 1402.00 35050.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 648 5433.50 271675.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 131 548.50 37232.18 67.88
OCCT-97530HM-OT SESSION BY OT ASST 7 22.00 1195.04 54.32
PHY-97110-PT SESSION BY LICENSED PT 111 433.25 29409.01 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 5.50 298.76 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 5 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 211 826.45 55997.61 67.76
SPL-92508-GROUP SPL SESSION PER CHILD 13 17.50 231.00 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 288 296.00 2368.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 648 129583 64791.55 0.50
Subtotal (Total Children Is Unduplicated) 1011 143342 621023.15 4.33
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Total 151098.30 931765.15 6.17
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Number of Children (Unduplicated) With at Least One Service 1588
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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 1583 1585.00 65953.50 0.00
P 5384 134085.30 290419.42 289467.53
D 154 309.25 6149.65 6149.65
S 0 0.00 0.00 0.00
H 1480 4947.75 241018.55 241033.26
T 0 0.00 0.00 0.00
5200 10171.00 328224.03 0.00
Other 0 0.00 0.00 0.00
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Total 13801 151098.30 931765.15 536650.44