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
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 27 74.75 2765.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 47 80.25 2969.25 37.00
Subtotal (Total Children Is Unduplicated) 74 155.00 5735.00 37.00
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 4 4.00 200.00 50.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 9 9.00 436.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 14 14.00 679.00 48.50
Subtotal (Total Children Is Unduplicated) 26 30.00 1461.00 48.70
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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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 191 1572.00 78600.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 49 207.50 14085.10 67.88
PHY-97110-PT SESSION BY LICENSED PT 23 96.25 6533.45 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 5 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 59 285.00 19345.80 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 693 137195 68597.50 0.50
Subtotal (Total Children Is Unduplicated) 740 139428 190386.85 1.37
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Total 139613.25 197582.85 1.42
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Number of Children (Unduplicated) With at Least One Service 803
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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 2234 125652.25 182575.63 176090.87
D 1 64.00 32.00 32.00
S 0 0.00 0.00 0.00
H 243 13742.00 9240.22 8901.32
T 0 0.00 0.00 0.00
284 155.00 5735.00 0.00
Other 0 0.00 0.00 0.00
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Total 2762 139613.25 197582.85 185024.19