CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Agency Filter:EXT
Payclass Filters:MED
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 115 223.25 8260.25 37.00
Subtotal (Total Children Is Unduplicated) 115 223.25 8260.25 37.00
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Screening, Eval, and Assessment,Class #02
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 15 15.00 727.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 14 14.00 679.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 31 32.00 1552.00 48.50
Subtotal (Total Children Is Unduplicated) 43 67.00 3249.50 48.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 371 3023.00 151100.00 49.98
OCCT-97530-OT SESSION BY LICENSED OT 31 128.25 8705.61 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 5.00 271.60 54.32
PHY-97110-PT SESSION BY LICENSED PT 49 199.75 13559.03 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 3.00 162.96 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 28 94.00 6380.72 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 13.20 13.20
Subtotal (Total Children Is Unduplicated) 426 3454.00 180193.12 52.17
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Total 3744.25 191702.87 51.20
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Number of Children (Unduplicated) With at Least One Service 502
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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 265 223.25 8260.25 0.00
P 4 12.00 634.26 634.26
D 4 5.50 283.94 283.94
S 0 0.00 0.00 0.00
H 940 3141.50 159075.90 159543.60
T 0 0.00 0.00 0.00
201 362.00 23448.52 0.00
Other 0 0.00 0.00 0.00
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Total 1414 3744.25 191702.87 160461.80