CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 0.75 27.75 37.00
Subtotal (Total Children Is Unduplicated) 1 0.75 27.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 16.50 1171.00 70.97
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 24 48.00 3600.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 23 36.00 1993.00 55.36
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 53 109.50 7200.50 65.76
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 86 445.00 22250.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 8 16.50 1118.08 67.76
OCCT-97530HM-OT SESSION BY OT ASST 2 10.00 543.20 54.32
PHY-97110-PT SESSION BY LICENSED PT 29 131.25 8873.37 67.61
PHY-97110HM-PT SESSION BY PT ASST 3 22.00 1195.04 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 109 570.25 38462.89 67.45
SPL-92508-GROUP SPL SESSION PER CHILD 2 3.25 42.90 13.20
Subtotal (Total Children Is Unduplicated) 200 1198.25 72485.48 60.49
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Total 1308.50 79713.73 60.92
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Number of Children (Unduplicated) With at Least One Service 239
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Center 01
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 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
499 1264.00 76854.07 0.00
Other 51 44.50 2859.66 0.00
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Total 550 1308.50 79713.73 0.00