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
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 25 27.75 1026.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 50 82.75 3061.75 37.00
Subtotal (Total Children Is Unduplicated) 73 110.50 4088.50 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 7 7.00 339.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 12 12.00 582.00 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 29 29.00 1406.50 48.50
Subtotal (Total Children Is Unduplicated) 52 64.00 3111.50 48.62
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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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 208 1770.00 88500.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 76 332.64 22579.87 67.88
PHY-97110-PT SESSION BY LICENSED PT 29 135.50 9197.74 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 11.00 550.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 88 462.23 31274.35 67.66
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 665 150009 75004.50 0.50
Subtotal (Total Children Is Unduplicated) 734 153136 244218.96 1.59
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Total 153310.12 251418.96 1.64
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Number of Children (Unduplicated) With at Least One Service 792
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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 3194 152472.12 243558.74 243558.80
D 16 570.00 1227.56 1190.56
S 0 0.00 0.00 0.00
H 18 158.50 2581.16 2547.25
T 0 0.00 0.00 0.00
212 109.50 4051.50 0.00
Other 0 0.00 0.00 0.00
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Total 3440 153310.12 251418.96 247296.61