CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 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 607 2137.75 79096.75 37.00
Subtotal (Total Children Is Unduplicated) 1305 3132.25 99132.25 31.65
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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 4 2.50 187.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 22 16.00 1200.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 6.50 360.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 49 26.50 1987.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 33 28.00 2100.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 83 77.00 4273.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 146 123.50 9262.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.00 740.00 185.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 9 9.00 436.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 21 21.00 1018.50 48.50
Subtotal (Total Children Is Unduplicated) 392 448.00 28337.25 63.25
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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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 191 1573.00 78650.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 49 207.50 14085.10 67.88
PHY-97110-PT SESSION BY LICENSED PT 23 96.25 6533.45 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 5 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 59 285.00 19345.80 67.88
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) 954 140243 193633.85 1.38
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Total 143823.50 321103.35 2.23
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Number of Children (Unduplicated) With at Least One Service 1580
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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 2243 126094.25 182796.63 176311.87
D 1 64.00 32.00 32.00
S 0 0.00 0.00 0.00
H 243 13742.00 9240.22 8901.32
T 0 0.00 0.00 0.00
5083 3923.25 129034.50 0.00
Other 0 0.00 0.00 0.00
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Total 7570 143823.50 321103.35 185245.19