CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 1677 1870.75 69217.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1293 1373.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 207 134.25 4931.25 36.73
TCM-T1017TL-TARGETED CASE MANAGEMENT 2395 21661.0 801438.50 37.00
Subtotal (Total Children Is Unduplicated) 2400 25039.0 875587.50 34.97
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 3 4.00 194.00 48.50
EVAL-EVAL-DEVELOPMENTAL EVALUATION 188 192.00 9600.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 146 139.50 6975.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 45 36.50 2737.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 19 17.00 1275.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 18 14.00 1050.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 144 198.00 14850.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 151 170.50 9462.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 244 189.00 14175.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 15.50 1162.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 164 133.50 10012.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 685 711.00 39460.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 553 641.00 48075.00 75.00
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 1 1.00 25.96 25.96
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 451 453.00 83660.50 184.68
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 16 16.00 4400.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 137 163.00 17115.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 11 11.00 1760.00 160.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 45 47.00 2279.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 65 69.00 3346.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 63 70.00 3395.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 27 30.00 1455.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 160 176.00 8536.00 48.50
Subtotal (Total Children Is Unduplicated) 1414 3497.50 285003.21 81.49
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 129 260.25 13012.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 10 6.00 150.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 186 696.50 34825.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 173 799.50 19987.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 71 223.00 11150.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 78 290.00 7250.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 12 24.50 1225.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 2 2.00 50.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 128 433.50 21675.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 125 509.00 12725.00 25.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 10 6.00 440.52 73.42
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 191 15013.0 375325.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 87 7577.00 189425.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 9 199.00 9950.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1017 17401.3 869862.50 49.99
OCCT-97530-OT SESSION BY LICENSED OT 188 1861.35 126119.69 67.76
OCCT-97530HM-OT SESSION BY OT ASST 10 17.00 923.44 54.32
PHY-97110-PT SESSION BY LICENSED PT 176 1801.00 122158.60 67.83
PHY-97110HM-PT SESSION BY PT ASST 4 10.50 570.36 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 9 23.00 1150.00 50.00
SIC-SIC-SPECIAL INSTRUCTION CONSULTATION 1 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 271 2274.19 154069.73 67.75
SPL-92508-GROUP SPL SESSION PER CHILD 7 14.00 184.80 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 1044 1193.00 8222.50 6.89
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 955 461498 230748.50 0.50
Subtotal (Total Children Is Unduplicated) 1667 512138 2211450.64 4.32
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Total 540674.04 3372041.35 6.24
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Number of Children (Unduplicated) With at Least One Service 2408
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Center 04
Flag Claims Units Chgs Paid
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R 29 31.50 1165.50 0.00
U 0 0.00 0.00 0.00
B 3088 2917.50 113193.75 0.00
P 23952 481382.31 1196203.25 1188335.16
D 973 2757.75 56242.46 30659.04
S 0 0.00 0.00 0.00
H 3725 12141.73 618863.61 619827.91
T 0 0.00 0.00 0.00
23107 41443.25 1386372.78 0.00
Other 0 0.00 0.00 0.00
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Total 54874 540674.04 3372041.35 1838822.11