CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EXT
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 32 13.50 499.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 124 238.00 8806.00 37.00
Subtotal (Total Children Is Unduplicated) 136 251.50 9305.50 37.00
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 9 9.00 450.00 50.00
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 37 37.00 1794.50 48.50
Subtotal (Total Children Is Unduplicated) 77 97.00 4718.00 48.64
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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 510 3513.00 175650.00 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
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 528 95198.0 47599.00 0.50
Subtotal (Total Children Is Unduplicated) 747 106891 507927.72 4.75
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Total 107239.70 521951.22 4.87
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Number of Children (Unduplicated) With at Least One Service 750
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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 256 188.50 6974.50 0.00
P 2249 97063.92 152221.58 152373.11
D 6 177.00 536.64 536.64
S 0 0.00 0.00 0.00
H 789 2521.28 129461.24 129371.38
T 0 0.00 0.00 0.00
1097 7289.00 232757.26 0.00
Other 0 0.00 0.00 0.00
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Total 4397 107239.70 521951.22 282281.13