CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EXT
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 78 48.00 1776.00 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 8 8.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 83 251.25 9296.25 37.00
Subtotal (Total Children Is Unduplicated) 143 307.25 11072.25 36.04
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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 45 47.00 2350.00 50.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 1.50 83.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 185.00 185.00
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 90 97.00 4704.50 48.50
Subtotal (Total Children Is Unduplicated) 189 260.42 12900.87 49.54
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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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 351 5294.00 264700.00 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 1 1.00 1.00 1.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 955 461468 230733.50 0.50
Subtotal (Total Children Is Unduplicated) 1122 471956 748923.95 1.59
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Total 472523.81 772897.07 1.64
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Number of Children (Unduplicated) With at Least One Service 1195
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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 11650 470239.56 748480.09 748638.45
D 120 1866.00 6568.06 6083.49
S 0 0.00 0.00 0.00
H 51 142.00 7707.92 7809.74
T 0 0.00 0.00 0.00
435 276.25 10141.00 0.00
Other 0 0.00 0.00 0.00
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Total 12256 472523.81 772897.07 762531.68