CMS/EIP Fiscal Report Center: 57
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 1 1.50 55.50 37.00
Subtotal (Total Children Is Unduplicated) 1 1.50 55.50 37.00
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 50.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 11 11.00 533.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.00 242.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 7 7.00 339.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.00 339.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 13.00 630.50 48.50
Subtotal (Total Children Is Unduplicated) 33 46.00 2266.00 49.26
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.00 25.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 265 2106.00 105200.00 49.95
OCCT-97530-OT SESSION BY LICENSED OT 41 90.50 6143.14 67.88
PHY-97110-PT SESSION BY LICENSED PT 50 141.00 9571.08 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 41 87.50 5939.50 67.88
Subtotal (Total Children Is Unduplicated) 310 2427.00 126928.72 52.30
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Total 2474.50 129250.22 52.23
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Number of Children (Unduplicated) With at Least One Service 313
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Center 57
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 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 8 27.00 1350.00 1350.00
H 0 0.00 0.00 0.00
T 21 68.00 3400.00 3400.00
842 2379.50 124500.22 106467.39
Other 0 0.00 0.00 0.00
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Total 871 2474.50 129250.22 111217.39