CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Agency Filter:EXT
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 25 27.75 1026.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 99 154.75 5725.75 37.00
Subtotal (Total Children Is Unduplicated) 111 182.50 6752.50 37.00
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 5 5.00 250.00 50.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 14 14.00 679.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 21 21.00 1018.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 14 14.00 679.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.00 436.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 52 52.00 2522.00 48.50
Subtotal (Total Children Is Unduplicated) 94 115.00 5585.00 48.57
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 26 30.25 1512.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 48 121.00 6050.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 28 73.00 1825.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 14 31.00 1550.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 10 27.00 675.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 5.00 250.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 36 82.00 4100.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 19 46.00 1150.00 25.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 86 2584.00 64600.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 47 1570.00 39250.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 654 5888.00 294400.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 142 790.99 53692.67 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 4.50 244.44 54.32
PHY-97110-PT SESSION BY LICENSED PT 95 436.50 29629.62 67.88
PHY-97110HM-PT SESSION BY PT ASST 5 20.00 1086.40 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 13.00 650.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 182 888.73 60225.17 67.77
SPL-92508-GROUP SPL SESSION PER CHILD 2 4.00 52.80 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 665 150009 75004.50 0.50
Subtotal (Total Children Is Unduplicated) 868 162624 635948.10 3.91
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Total 162921.47 648285.60 3.98
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Number of Children (Unduplicated) With at Least One Service 871
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Center 04
Flag Claims Units Chgs Paid
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R 1 0.50 18.50 0.00
U 0 0.00 0.00 0.00
B 34 26.25 971.25 0.00
P 3282 152590.87 249147.87 249147.93
D 19 580.50 1763.36 1760.26
S 0 0.00 0.00 0.00
H 1403 4664.10 238408.95 238527.33
T 0 0.00 0.00 0.00
980 5059.25 157975.67 450.00
Other 0 0.00 0.00 0.00
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Total 5719 162921.47 648285.60 489885.52