CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2008 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 227 906.75 33549.75 37.00
Subtotal (Total Children Is Unduplicated) 227 906.75 33549.75 37.00
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Screening, Eval, and Assessment,Class #02
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 26 27.00 1309.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 22 22.00 1067.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 34 40.00 1940.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.00 436.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 62 70.00 3395.00 48.50
Subtotal (Total Children Is Unduplicated) 99 168.00 8148.00 48.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 621 11249.0 562250.00 49.98
OCCT-97530-OT SESSION BY LICENSED OT 64 562.00 38148.56 67.88
OCCT-97530HM-OT SESSION BY OT ASST 4 8.00 434.56 54.32
PHY-97110-PT SESSION BY LICENSED PT 65 666.25 45225.05 67.88
PHY-97110HM-PT SESSION BY PT ASST 3 4.50 244.44 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 53 407.50 27661.10 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 3 6.00 79.20 13.20
Subtotal (Total Children Is Unduplicated) 697 12903.3 674042.91 52.24
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Total 13978.00 715740.66 51.20
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Number of Children (Unduplicated) With at Least One Service 836
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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 283 211.00 7807.00 0.00
P 889 725.00 27260.76 27260.76
D 13 24.50 1323.34 1323.34
S 0 0.00 0.00 0.00
H 3525 11691.50 591817.22 592517.13
T 0 0.00 0.00 0.00
599 1326.00 87532.34 0.00
Other 0 0.00 0.00 0.00
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Total 5309 13978.00 715740.66 621101.23