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: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 70 72.00 2664.00 37.00
Subtotal (Total Children Is Unduplicated) 70 72.00 2664.00 37.00
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Screening, Eval, and Assessment,Class #02
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 7 7.00 339.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.00 291.00 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 18 18.00 873.00 48.50
Subtotal (Total Children Is Unduplicated) 34 42.00 2037.00 48.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 449 3877.00 193850.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 46 295.00 20024.60 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 4.50 244.44 54.32
PHY-97110-PT SESSION BY LICENSED PT 25 158.75 10775.95 67.88
PHY-97110HM-PT SESSION BY PT ASST 4 14.50 787.64 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 2.00 100.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 28 142.25 9655.93 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.00 26.40 13.20
Subtotal (Total Children Is Unduplicated) 489 4496.00 235464.96 52.37
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Total 4610.00 240165.96 52.10
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Number of Children (Unduplicated) With at Least One Service 565
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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 69 54.75 2247.59 2247.59
D 3 10.50 535.80 569.70
S 0 0.00 0.00 0.00
H 1268 4225.00 217226.92 217568.26
T 0 0.00 0.00 0.00
115 293.00 19165.90 450.00
Other 0 0.00 0.00 0.00
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Total 1490 4610.00 240165.96 220835.55