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: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 698 2402.75 88901.75 37.00
Subtotal (Total Children Is Unduplicated) 1375 3378.50 107651.50 31.86
----------------------------------------------------------------------------------------------------------------
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 6 3.00 225.00 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 5 2.50 187.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 39 30.50 2287.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 13.00 721.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 35 20.50 1537.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 1.00 75.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 35 25.50 1912.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 85 72.00 3996.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 150 120.00 9000.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 9 9.00 1665.00 185.00
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) 406 477.00 30573.00 64.09
----------------------------------------------------------------------------------------------------------------
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 211 1576.50 78825.00 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 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) 975 132897 198036.55 1.49
----------------------------------------------------------------------------------------------------------------
Total 136752.80 336261.05 2.46
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1584
----------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
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 2590 131861.30 185850.42 185947.99
D 163 311.50 6180.90 6180.90
S 0 0.00 0.00 0.00
H 76 572.50 12393.98 11828.38
T 0 0.00 0.00 0.00
5214 4007.50 131835.75 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 8043 136752.80 336261.05 203957.27