CMS/EIP Fiscal Report Center: 57
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 5 5.25 194.25 37.00
Subtotal (Total Children Is Unduplicated) 5 5.25 194.25 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 50.00 50.00
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 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 3 3.00 145.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 18 18.00 873.00 48.50
Subtotal (Total Children Is Unduplicated) 25 35.00 1706.00 48.74
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 276 2299.50 114975.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 34 164.00 11132.32 67.88
PHY-97110-PT SESSION BY LICENSED PT 41 179.00 12146.52 67.86
PHY-97110HM-PT SESSION BY PT ASST 2 3.00 162.92 54.31
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 40 163.25 11081.41 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.00 52.80 13.20
Subtotal (Total Children Is Unduplicated) 324 2813.75 149600.97 53.17
----------------------------------------------------------------------------------------------------------------
Total 2854.00 151501.22 53.08
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 330
----------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 1 0.50 18.50 0.00
P 7 4.75 175.75 175.75
D 0 0.00 0.00 0.00
S 7 20.00 1000.00 1000.00
H 0 0.00 0.00 0.00
T 13 41.50 2136.58 2136.58
981 2787.25 148170.39 116429.27
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1009 2854.00 151501.22 119741.60