CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 635 501.75 18564.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 403 412.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 24 15.25 564.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1507 5795.00 214378.00 36.99
Subtotal (Total Children Is Unduplicated) 1550 6724.00 233507.00 34.73
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 48 47.00 2350.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 61 53.50 2675.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 5.50 412.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 6.00 450.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 12 11.00 825.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 40 42.50 3187.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 41 42.50 2358.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 75 41.00 3075.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 1.50 38.00 25.33
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 84 60.50 4537.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 224 210.50 11628.75 55.24
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 171 186.50 13987.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 150 150.00 27750.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.00 550.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 31 31.00 3255.00 105.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 10 10.00 485.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 51 51.00 2473.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 8 8.00 388.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 23 23.00 1115.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 85 86.00 4171.00 48.50
Subtotal (Total Children Is Unduplicated) 540 1069.00 85713.50 80.18
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 30 38.75 1937.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 5.50 275.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 1.00 25.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 1.75 87.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 1.00 25.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.00 50.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 1.75 87.50 50.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.00 73.42 73.42
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 93 6469.00 161725.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 40 1545.00 38625.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 774 6778.50 338925.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 176 1014.25 68847.29 67.88
PHY-97110-PT SESSION BY LICENSED PT 104 614.00 41678.32 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 219 1020.00 69237.60 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 22 78.00 4236.96 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 13 24.00 316.80 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 321 327.00 2616.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 774 159118 79559.00 0.50
Subtotal (Total Children Is Unduplicated) 1104 177041 808382.21 4.57
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Total 184833.50 1127602.71 6.10
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Number of Children (Unduplicated) With at Least One Service 1655
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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 1567 1654.00 65385.00 0.00
P 5830 163237.50 344372.62 340556.23
D 72 69.50 2571.50 2571.50
S 1 2.00 74.00 0.00
H 1972 7379.00 325453.82 325154.40
T 0 0.00 0.00 0.00
5058 12491.50 389745.77 300.00
Other 0 0.00 0.00 0.00
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Total 14500 184833.50 1127602.71 668582.13