CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 27 74.75 2765.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 100 157.50 5827.50 37.00
Subtotal (Total Children Is Unduplicated) 124 232.25 8593.25 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 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 41 41.00 1988.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 6.00 291.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 13 13.00 630.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 43 44.00 2134.00 48.50
Subtotal (Total Children Is Unduplicated) 90 110.00 5341.00 48.55
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 22 31.00 1550.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 8 9.00 450.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 5 8.00 200.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.00 100.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 4 4.00 100.00 25.00
CONPP-CONPP-CONSULT, PT, PHONE 1 1.00 25.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 9 9.50 475.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 3 3.00 75.00 25.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 98 8852.00 221300.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 51 1757.00 43925.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 681 5559.00 277950.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 163 777.25 52759.73 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 4.00 217.28 54.32
PHY-97110-PT SESSION BY LICENSED PT 127 511.25 34703.65 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 5.00 271.60 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 5 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 206 899.00 61024.12 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 34 50.50 666.60 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 693 137195 68597.50 0.50
Subtotal (Total Children Is Unduplicated) 917 155683 764640.48 4.91
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Total 156024.75 778574.73 4.99
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Number of Children (Unduplicated) With at Least One Service 923
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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 32 25.75 952.75 0.00
P 2315 125755.75 187276.31 180749.05
D 1 64.00 32.00 32.00
S 0 0.00 0.00 0.00
H 1712 18149.25 242388.83 242091.41
T 0 0.00 0.00 0.00
1205 12030.00 347924.84 403.64
Other 0 0.00 0.00 0.00
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Total 5265 156024.75 778574.73 423276.10