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
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 32 13.50 499.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 26 44.75 1655.75 37.00
Subtotal (Total Children Is Unduplicated) 52 58.25 2155.25 37.00
----------------------------------------------------------------------------------------------------------------
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 6 6.00 291.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 15 16.00 776.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.00 291.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 24 24.00 1164.00 48.50
Subtotal (Total Children Is Unduplicated) 51 65.00 3166.00 48.71
----------------------------------------------------------------------------------------------------------------
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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 160 996.00 49800.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 45 144.42 9803.14 67.88
PHY-97110-PT SESSION BY LICENSED PT 20 90.50 6143.14 67.88
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 47 244.00 16562.72 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.00 39.60 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 528 95198.0 47599.00 0.50
Subtotal (Total Children Is Unduplicated) 596 97234.4 152797.60 1.57
----------------------------------------------------------------------------------------------------------------
Total 97357.67 158118.85 1.62
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 654
----------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
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 2242 97043.92 151171.18 151322.71
D 6 177.00 536.64 536.64
S 0 0.00 0.00 0.00
H 27 78.50 4255.78 4357.60
T 0 0.00 0.00 0.00
104 58.25 2155.25 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 2379 97357.67 158118.85 156216.95