CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 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 31 32.75 1211.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 133 229.25 8482.25 37.00
Subtotal (Total Children Is Unduplicated) 157 262.00 9694.00 37.00
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 4 4.00 200.00 50.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 11 11.00 533.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 31 31.00 1503.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 30 41.00 1988.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 82 83.00 4025.50 48.50
Subtotal (Total Children Is Unduplicated) 124 174.00 8445.00 48.53
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 40 42.50 2125.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 23 45.50 2275.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 18 33.00 825.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 6 13.00 650.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 7 14.00 350.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.00 50.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 17 29.50 1475.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 12 18.00 450.00 25.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 101 4573.00 114325.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 64 1402.00 35050.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 641 5414.50 270725.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 131 548.50 37232.18 67.88
OCCT-97530HM-OT SESSION BY OT ASST 7 22.00 1195.04 54.32
PHY-97110-PT SESSION BY LICENSED PT 111 433.25 29409.01 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 5.50 298.76 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 5 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 211 826.45 55997.61 67.76
SPL-92508-GROUP SPL SESSION PER CHILD 13 17.50 231.00 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 648 129583 64791.55 0.50
Subtotal (Total Children Is Unduplicated) 868 143027 617705.15 4.32
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Total 143463.30 635844.15 4.43
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Number of Children (Unduplicated) With at Least One Service 880
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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 79 66.00 2442.00 0.00
P 2624 131379.05 187057.92 186865.22
D 9 161.00 664.40 664.40
S 0 0.00 0.00 0.00
H 1479 4942.75 240768.55 240783.26
T 0 0.00 0.00 0.00
947 6914.50 204911.28 0.00
Other 0 0.00 0.00 0.00
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Total 5138 143463.30 635844.15 428312.88