CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Agency Filter:EXT
Payclass Filters:GR
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
CASE-CASE-NON-TCM CASE MANAGEMENT 30 29.00 1073.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 51 107.75 3986.75 37.00
Subtotal (Total Children Is Unduplicated) 77 136.75 5059.75 37.00
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.00 48.50 48.50
EVAL-EVAL-DEVELOPMENTAL EVALUATION 5 5.00 250.00 50.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 16 16.00 776.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 25 25.00 1212.50 48.50
Subtotal (Total Children Is Unduplicated) 53 59.00 2869.00 48.63
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 21 30.75 1537.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 76 148.00 7400.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 39 76.00 1900.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 22 38.00 1900.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 15 29.00 725.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 10.50 525.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 61 102.00 5100.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 25 47.00 1175.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 184 1131.75 56587.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 64 255.00 17309.40 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 1.50 81.48 54.32
PHY-97110-PT SESSION BY LICENSED PT 24 125.47 8516.83 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 3.00 150.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 70 394.80 26799.03 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 584 107219 53609.50 0.50
Subtotal (Total Children Is Unduplicated) 645 109612 183316.24 1.67
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Total 109807.52 191244.99 1.74
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Number of Children (Unduplicated) With at Least One Service 710
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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 0 0.00 0.00 0.00
P 2472 109511.77 183677.24 183678.51
D 9 131.00 1036.48 1056.82
S 0 0.00 0.00 0.00
H 10 28.00 1471.52 1471.52
T 0 0.00 0.00 0.00
249 136.75 5059.75 0.00
Other 0 0.00 0.00 0.00
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Total 2740 109807.52 191244.99 186206.85