CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 667 467.00 17279.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 338 339.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 33 21.75 804.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1500 5630.50 208328.50 37.00
Subtotal (Total Children Is Unduplicated) 1541 6458.25 226412.25 35.06
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 51 51.50 2575.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 80 72.00 3600.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 6.00 450.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 4.50 337.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 27 33.50 2512.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 19.50 1082.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 65 37.00 2775.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 3.00 225.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 77 59.50 4462.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 195 178.00 9879.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 133 134.00 10050.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 106 106.00 19610.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 275.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 24 24.00 2520.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 160.00 160.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 41 41.00 1988.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 6.00 291.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 13 13.00 630.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 48 49.00 2376.50 48.50
Subtotal (Total Children Is Unduplicated) 474 845.50 66197.25 78.29
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 22 31.00 1550.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 8 9.00 450.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 5 8.00 200.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.00 100.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 4 4.00 100.00 25.00
CONPP-CONPP-CONSULT, PT, PHONE 1 1.00 25.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 9 9.50 475.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 3 3.00 75.00 25.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 98 8852.00 221300.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 51 1757.00 43925.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 683 5562.00 278100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 163 777.25 52759.73 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 4.00 217.28 54.32
PHY-97110-PT SESSION BY LICENSED PT 127 511.25 34703.65 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 5.00 271.60 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 5 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 206 899.00 61024.12 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 34 50.50 666.60 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 289 292.00 2336.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 693 137195 68597.50 0.50
Subtotal (Total Children Is Unduplicated) 1042 155978 767126.48 4.92
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Total 163281.25 1059735.98 6.49
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Number of Children (Unduplicated) With at Least One Service 1627
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Center 04
Flag Claims Units Chgs Paid
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R 283 303.25 11974.25 0.00
U 0 0.00 0.00 0.00
B 1736 1768.00 72466.75 0.00
P 4225 127722.50 260269.06 253988.67
D 1 64.00 32.00 32.00
S 0 0.00 0.00 0.00
H 1712 18149.25 242388.83 242091.41
T 1 1.25 46.25 0.00
5293 15273.00 472558.84 403.64
Other 0 0.00 0.00 0.00
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Total 13251 163281.25 1059735.98 496515.72