CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 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 31 32.75 1211.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 67 121.00 4477.00 37.00
Subtotal (Total Children Is Unduplicated) 96 153.75 5688.75 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 4 4.00 194.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 10 10.00 485.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 15 25.00 1212.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 31 31.00 1503.50 48.50
Subtotal (Total Children Is Unduplicated) 50 76.00 3692.00 48.58
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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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 208 1566.50 78325.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 53 178.50 12116.58 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 8.00 434.56 54.32
PHY-97110-PT SESSION BY LICENSED PT 28 102.75 6974.67 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 5 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 80 340.95 23118.69 67.81
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 648 129583 64791.55 0.50
Subtotal (Total Children Is Unduplicated) 723 131981 194211.05 1.47
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Total 132211.05 203591.80 1.54
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Number of Children (Unduplicated) With at Least One Service 779
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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 2574 131327.80 185044.67 184851.97
D 8 157.00 464.40 464.40
S 0 0.00 0.00 0.00
H 76 572.50 12393.98 11828.38
T 0 0.00 0.00 0.00
204 153.75 5688.75 0.00
Other 0 0.00 0.00 0.00
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Total 2862 132211.05 203591.80 197144.75