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: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 767 518.75 19193.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 452 453.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 34 22.75 841.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1729 6554.25 242507.25 37.00
Subtotal (Total Children Is Unduplicated) 1770 7548.75 262542.75 34.78
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 56 56.00 2800.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 80 72.00 3600.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 6.50 487.50 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 6 4.50 337.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 28 34.50 2587.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 22 21.00 1165.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 113 62.00 4613.50 74.41
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 101 74.50 5587.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 275 244.00 13487.50 55.28
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 184 186.00 13950.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 138 138.00 25530.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.00 825.00 275.00
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 50 51.00 2473.50 48.50
Subtotal (Total Children Is Unduplicated) 588 1048.50 83769.50 79.89
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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 686 5587.00 279350.00 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 128 519.25 35246.69 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 368 372.00 2976.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 696 137637 68818.50 0.50
Subtotal (Total Children Is Unduplicated) 1124 156533 769780.52 4.92
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Total 165129.75 1116092.77 6.76
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Number of Children (Unduplicated) With at Least One Service 1856
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Center 04
Flag Claims Units Chgs Paid
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R 322 337.50 13468.00 0.00
U 0 0.00 0.00 0.00
B 2034 2071.75 85554.00 0.00
P 4432 128391.25 268917.81 262628.60
D 1 64.00 32.00 32.00
S 0 0.00 0.00 0.00
H 1721 18182.25 244181.87 243884.45
T 1 1.25 46.25 0.00
6286 16081.75 503892.84 403.64
Other 0 0.00 0.00 0.00
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Total 14797 165129.75 1116092.77 506948.69