CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 Page: 1
Payclass Filters:GR
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 579 2000.75 74027.75 37.00
Subtotal (Total Children Is Unduplicated) 1165 2780.50 89965.50 32.36
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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 4 2.00 150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 3.00 225.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.50 37.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 38 30.00 2250.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 8.00 444.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 13.00 975.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 0.50 37.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 24 18.00 1350.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 55 49.00 2719.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 113 91.50 6862.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 7 7.00 1295.00 185.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 4.00 194.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 10 10.00 485.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 15 25.00 1212.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 32 32.00 1552.00 48.50
Subtotal (Total Children Is Unduplicated) 331 390.00 24611.50 63.11
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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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 210 1569.50 78475.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 53 178.50 12116.58 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 8.00 434.56 54.32
PHY-97110-PT SESSION BY LICENSED PT 28 102.75 6974.67 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 5 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 80 340.95 23118.69 67.81
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) 886 132280 196729.05 1.49
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Total 135450.80 311306.05 2.30
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Number of Children (Unduplicated) With at Least One Service 1372
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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 2578 131331.30 185238.92 185336.49
D 150 301.50 5810.90 5810.90
S 0 0.00 0.00 0.00
H 76 572.50 12393.98 11828.38
T 0 0.00 0.00 0.00
4303 3245.50 107862.25 0.00
Other 0 0.00 0.00 0.00
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Total 7107 135450.80 311306.05 202975.77