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: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 725 555.50 20553.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 498 507.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 26 16.25 601.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1720 6614.50 244699.50 36.99
Subtotal (Total Children Is Unduplicated) 1765 7693.25 265854.25 34.56
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 56 54.00 2700.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 61 53.50 2675.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 6.00 450.00 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 13 11.50 862.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 43 46.50 3487.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 44 45.50 2525.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 95 51.50 3862.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 2.50 113.00 45.20
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 109 78.00 5850.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 284 262.50 14514.75 55.29
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 219 233.00 17475.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 190 190.00 35150.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.00 550.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 33 33.00 3465.00 105.00
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 87 88.00 4268.00 48.50
Subtotal (Total Children Is Unduplicated) 636 1255.50 102860.50 81.93
----------------------------------------------------------------------------------------------------------------
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 777 6800.50 340025.00 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 387 396.00 3168.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 777 159430 79715.00 0.50
Subtotal (Total Children Is Unduplicated) 1172 177444 810190.21 4.57
----------------------------------------------------------------------------------------------------------------
Total 186392.25 1178904.96 6.32
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1870
----------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 1799 1907.50 75726.75 0.00
P 6156 163850.00 358688.62 353821.70
D 87 81.00 2997.00 2997.00
S 1 2.00 74.00 0.00
H 1978 7401.00 326553.82 326254.40
T 0 0.00 0.00 0.00
5881 13150.75 414864.77 300.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 15902 186392.25 1178904.96 683373.10