CMS/EIP Fiscal Report Center: 57
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 12 28.25 1045.25 37.00
Subtotal (Total Children Is Unduplicated) 12 28.25 1045.25 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 2 2.00 111.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.00 300.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 25 27.00 1309.50 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 24 28.00 1358.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 19 19.00 921.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 45 50.00 2425.00 48.50
Subtotal (Total Children Is Unduplicated) 81 138.00 6841.00 49.57
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 3 6.00 417.10 69.52
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.00 25.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 480 8034.00 401100.00 49.93
OCCT-97530-OT SESSION BY LICENSED OT 48 277.00 18802.76 67.88
OCCT-97530HM-OT SESSION BY OT ASST 31 744.00 40414.08 54.32
PHY-97110-PT SESSION BY LICENSED PT 69 445.00 30202.60 67.87
PHY-97110HM-PT SESSION BY PT ASST 33 655.00 35579.56 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 4 7.00 350.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 56 281.75 19125.19 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 35 822.00 10850.40 13.20
Subtotal (Total Children Is Unduplicated) 555 11272.8 556866.69 49.40
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Total 11439.00 564752.94 49.37
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Number of Children (Unduplicated) With at Least One Service 563
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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 4 16.75 619.75 0.00
P 16 11.50 425.50 425.50
D 0 0.00 0.00 0.00
S 24 64.00 3185.76 3185.76
H 0 0.00 0.00 0.00
T 68 210.50 10622.34 10622.34
3345 11136.25 549899.59 390347.17
Other 0 0.00 0.00 0.00
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Total 3457 11439.00 564752.94 404580.77