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: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 97 161.75 5984.75 37.00
Subtotal (Total Children Is Unduplicated) 97 161.75 5984.75 37.00
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Screening, Eval, and Assessment,Class #02
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 4.00 194.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 7 7.00 339.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 9.00 436.50 48.50
Subtotal (Total Children Is Unduplicated) 23 26.00 1261.00 48.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 367 2297.00 114850.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 42 212.50 14424.50 67.88
PHY-97110-PT SESSION BY LICENSED PT 26 156.75 10640.19 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 3.00 150.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 22 146.84 9967.50 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.00 26.40 13.20
Subtotal (Total Children Is Unduplicated) 405 2818.09 150058.59 53.25
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Total 3005.84 157304.34 52.33
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Number of Children (Unduplicated) With at Least One Service 486
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Center 04
Flag Claims Units Chgs Paid
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R 1 1.00 37.00 0.00
U 0 0.00 0.00 0.00
B 117 102.75 3801.75 0.00
P 107 74.25 3039.77 3039.77
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 777 2485.34 127529.54 127771.86
T 0 0.00 0.00 0.00
115 342.50 22896.28 0.00
Other 0 0.00 0.00 0.00
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Total 1117 3005.84 157304.34 130811.63