CMS/EIP Fiscal Report Center: 04
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 98 193.25 7150.25 37.00
Subtotal (Total Children Is Unduplicated) 98 193.25 7150.25 37.00
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Screening, Eval, and Assessment,Class #02
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.00 291.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 6.00 291.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 12 12.00 582.00 48.50
Subtotal (Total Children Is Unduplicated) 21 27.00 1309.50 48.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 343 2247.00 112350.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 36 166.25 11285.05 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 1.00 54.32 54.32
PHY-97110-PT SESSION BY LICENSED PT 22 154.25 10470.49 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.50 81.48 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 18 138.25 9384.41 67.88
Subtotal (Total Children Is Unduplicated) 373 2708.25 143625.75 53.03
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Total 2928.50 152085.50 51.93
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Number of Children (Unduplicated) With at Least One Service 463
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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 256 188.50 6974.50 0.00
P 3 3.00 111.00 111.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 721 2359.00 119763.62 119488.42
T 0 0.00 0.00 0.00
135 378.00 25236.38 0.00
Other 0 0.00 0.00 0.00
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Total 1115 2928.50 152085.50 119599.42