CMS/EIP Fiscal Report Center: 57
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 22 30.75 1137.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 10 10.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 0.50 18.50 37.00
Subtotal (Total Children Is Unduplicated) 26 41.25 1156.25 28.03
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 7 7.00 350.00 50.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 16 16.00 776.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 7 7.00 339.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.00 416.50 46.28
SPCH-92506-SPEECH EVAL BY LICENSED SLP 60 60.00 2910.00 48.50
Subtotal (Total Children Is Unduplicated) 87 101.00 4889.00 48.41
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 9.25 462.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 308 598.50 29762.50 49.73
CONIP-CONIP-CONSULT, ITDS, PHONE 258 519.75 12981.25 24.98
CONOF-CONOF-CONSULT, OT, FACE TO FACE 10 16.00 800.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 5.75 287.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 6 8.25 206.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 296 575.00 28750.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 255 520.50 13012.50 25.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 9 58.00 2030.00 35.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 40.00 720.00 18.00
EIIF-90801-PSYCHIATRIC DIAG INTERVIEW 1 8.00 400.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 372 3169.25 158087.50 49.88
OCCT-97530-OT SESSION BY LICENSED OT 22 105.00 7127.40 67.88
PHY-97110-PT SESSION BY LICENSED PT 41 159.75 10695.31 66.95
SHIN-EIIF_NM-INITIAL SHINE SERVICES, IND NONMED 1 1.00 50.00 50.00
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 2.00 100.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 113 476.75 32116.19 67.36
TRAN-TRAN-FAMILY TRANSPORTATION 2 135.00 121.50 0.90
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 666 141371 71122.80 0.50
Subtotal (Total Children Is Unduplicated) 742 147779 368839.45 2.50
----------------------------------------------------------------------------------------------------------------
Total 147921.25 374884.70 2.53
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 789
----------------------------------------------------------------------------------------------------------------
Center 57
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 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 229 5276.50 13545.14 13545.14
H 0 0.00 0.00 0.00
T 5536 142632.75 361137.06 362195.06
6 12.00 202.50 202.50
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 5771 147921.25 374884.70 375942.70