CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2008 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 704 408.75 15123.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 325 327.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 41 24.25 897.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1385 5123.75 189578.75 37.00
Subtotal (Total Children Is Unduplicated) 1408 5883.75 205599.75 34.94
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 55 56.50 2825.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 40 39.00 1950.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 8.00 600.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 3.50 262.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 4.50 337.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 39 47.00 3525.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 39 35.00 1942.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 54 32.50 2437.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 6.50 487.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 57 42.00 3150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 169 163.50 9074.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 115 119.00 8925.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 90 90.00 16650.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.00 825.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 43 43.00 4515.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 2 2.00 320.00 160.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 8 8.00 388.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 25 26.00 1261.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 10 10.00 485.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.00 339.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 38 38.00 1843.00 48.50
Subtotal (Total Children Is Unduplicated) 418 784.00 62143.25 79.26
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 39 50.00 2500.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 88 151.00 7550.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 55 101.00 2525.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 25 45.00 2250.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 20 36.00 900.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 8 10.50 525.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 1.00 25.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 60 93.00 4650.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 39 65.00 1625.00 25.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 106 3818.00 95450.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 55 2134.00 53350.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 521 3533.00 176650.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 105 498.20 33787.26 67.82
OCCT-97530HM-OT SESSION BY OT ASST 1 1.00 54.32 54.32
PHY-97110-PT SESSION BY LICENSED PT 99 484.50 32887.86 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.50 81.48 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SIC-SIC-SPECIAL INSTRUCTION CONSULTATION 1 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 149 680.00 46158.40 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 2 4.50 59.40 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 287 302.00 2226.00 7.37
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 528 95198.0 47599.00 0.50
Subtotal (Total Children Is Unduplicated) 907 107213 511153.72 4.77
----------------------------------------------------------------------------------------------------------------
Total 113880.95 778896.72 6.84
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1493
----------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 23 28.25 1045.25 0.00
U 0 0.00 0.00 0.00
B 2683 2546.50 97820.25 0.00
P 3247 97937.17 186122.33 185898.41
D 123 320.00 5840.64 5790.64
S 0 0.00 0.00 0.00
H 789 2521.28 129461.24 129371.38
T 0 0.00 0.00 0.00
5335 10527.75 358607.01 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 12200 113880.95 778896.72 321060.43