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: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 797 475.00 17575.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 469 469.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 45 31.75 1174.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1737 7054.50 261016.50 37.00
Subtotal (Total Children Is Unduplicated) 1761 8030.25 279766.25 34.84
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 59 55.50 2775.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 52 48.50 2425.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 11.50 862.50 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 9 5.00 375.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 46 44.50 3337.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 56 54.50 3024.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 102 57.50 4312.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 4.00 300.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 91 66.00 4950.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 259 220.50 12237.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 190 176.00 13200.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 139 139.00 25715.00 185.00
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 31 42.00 2037.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 83 84.00 4074.00 48.50
Subtotal (Total Children Is Unduplicated) 609 1098.00 86654.50 78.92
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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 651 5461.50 273075.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 132 556.00 37741.28 67.88
OCCT-97530HM-OT SESSION BY OT ASST 7 22.00 1195.04 54.32
PHY-97110-PT SESSION BY LICENSED PT 112 434.25 29476.89 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 212 830.45 56269.13 67.76
SPL-92508-GROUP SPL SESSION PER CHILD 13 17.50 231.00 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 374 383.00 3064.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 651 130106 65053.05 0.50
Subtotal (Total Children Is Unduplicated) 1101 143993 624229.15 4.34
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Total 153121.05 990649.90 6.47
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Number of Children (Unduplicated) With at Least One Service 1829
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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 1866 1886.75 79528.25 0.00
P 5707 134976.80 305331.92 304391.79
D 167 319.25 6519.65 6519.65
S 0 0.00 0.00 0.00
H 1491 4982.25 242965.55 242980.26
T 0 0.00 0.00 0.00
6134 10956.00 356304.53 0.00
Other 0 0.00 0.00 0.00
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Total 15365 153121.05 990649.90 553891.70