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: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 53 77.25 2858.25 37.00
Subtotal (Total Children Is Unduplicated) 53 77.25 2858.25 37.00
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Screening, Eval, and Assessment,Class #02
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 23 23.00 1115.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 11 11.00 533.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 22 23.00 1115.50 48.50
Subtotal (Total Children Is Unduplicated) 50 63.00 3055.50 48.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 479 3626.00 181300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 65 320.50 21755.54 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 4.00 217.28 54.32
PHY-97110-PT SESSION BY LICENSED PT 48 205.25 13932.37 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 5.00 271.60 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 45 238.75 16206.35 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 3 8.50 112.20 13.20
Subtotal (Total Children Is Unduplicated) 532 4408.00 233795.34 53.04
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Total 4548.25 239709.09 52.70
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Number of Children (Unduplicated) With at Least One Service 579
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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 69 57.50 2205.50 2163.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 1287 4042.50 208806.74 208848.22
T 0 0.00 0.00 0.00
151 422.50 27744.10 403.64
Other 0 0.00 0.00 0.00
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Total 1539 4548.25 239709.09 211414.86