CMS/EIP Fiscal Report Center: 57
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 21 11.75 434.75 37.00
Subtotal (Total Children Is Unduplicated) 21 11.75 434.75 37.00
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Screening, Eval, and Assessment,Class #02
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.00 436.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 15 15.00 727.50 48.50
Subtotal (Total Children Is Unduplicated) 29 30.00 1455.00 48.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 355 3119.00 155900.00 49.98
OCCT-97530-OT SESSION BY LICENSED OT 33 83.00 5634.04 67.88
PHY-97110-PT SESSION BY LICENSED PT 38 112.00 7602.56 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 2.50 135.80 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 2.00 100.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 54 133.25 8875.31 66.61
Subtotal (Total Children Is Unduplicated) 409 3451.75 178247.71 51.64
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Total 3493.50 180137.46 51.56
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Number of Children (Unduplicated) With at Least One Service 417
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Center 57
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 1 1.00 37.00 0.00
P 21 10.75 397.75 397.75
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 11 34.00 1735.76 1735.76
1086 3447.75 177966.95 164327.91
Other 0 0.00 0.00 0.00
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Total 1119 3493.50 180137.46 166461.42