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
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 66 108.25 4005.25 37.00
Subtotal (Total Children Is Unduplicated) 66 108.25 4005.25 37.00
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Screening, Eval, and Assessment,Class #02
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 6.00 291.00 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 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 12 12.00 582.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 38 38.00 1843.00 48.50
Subtotal (Total Children Is Unduplicated) 52 70.00 3395.00 48.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 444 3741.00 187050.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 40 183.50 12455.98 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 6.50 353.08 54.32
PHY-97110-PT SESSION BY LICENSED PT 34 160.75 10911.71 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 159.50 10826.86 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 3 5.00 66.00 13.20
Subtotal (Total Children Is Unduplicated) 489 4257.25 221717.95 52.08
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Total 4435.50 229118.20 51.66
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Number of Children (Unduplicated) With at Least One Service 541
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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 50 51.25 2013.25 2013.25
D 1 4.00 200.00 200.00
S 0 0.00 0.00 0.00
H 1204 3977.50 202631.50 203191.45
T 0 0.00 0.00 0.00
150 336.75 21831.45 0.00
Other 0 0.00 0.00 0.00
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Total 1484 4435.50 229118.20 205404.70