CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:GR
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 1277 1357.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 207 134.25 4931.25 36.73
TCM-T1017TL-TARGETED CASE MANAGEMENT 1202 8221.75 304195.50 37.00
Subtotal (Total Children Is Unduplicated) 2188 11583.8 378344.50 32.66
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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 182 186.00 9300.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 146 139.50 6975.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 40 33.00 2475.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 16.50 1237.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 14 10.50 787.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 132 170.50 12787.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 127 135.50 7520.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 197 156.50 11737.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 11.00 825.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 112 91.50 6862.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 505 530.00 29415.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 499 559.00 41925.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 108 109.00 20165.00 185.00
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
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 3 3.00 480.00 160.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 19 20.00 970.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 39 40.92 1984.62 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 29 30.00 1455.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 17 17.00 824.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 93 100.00 4850.00 48.50
Subtotal (Total Children Is Unduplicated) 1245 2398.42 166785.87 69.54
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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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 493 5429.25 271462.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 88 657.32 44530.82 67.75
OCCT-97530HM-OT SESSION BY OT ASST 2 3.50 190.12 54.32
PHY-97110-PT SESSION BY LICENSED PT 52 330.00 22349.60 67.73
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 128 927.07 62929.31 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.00 39.60 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 1044 1193.00 8222.50 6.89
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 955 461468 230733.50 0.50
Subtotal (Total Children Is Unduplicated) 1564 473289 764348.47 1.62
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Total 487271.56 1309478.84 2.69
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Number of Children (Unduplicated) With at Least One Service 2290
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Center 04
Flag Claims Units Chgs Paid
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R 19 17.75 656.75 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 11651 470239.81 748489.34 748647.70
D 900 2661.00 49518.06 28153.99
S 0 0.00 0.00 0.00
H 51 142.00 7707.92 7809.74
T 0 0.00 0.00 0.00
19070 14211.00 503106.77 0.00
Other 0 0.00 0.00 0.00
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Total 31691 487271.56 1309478.84 784611.43