CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 44 66.50 2460.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 121 203.75 7538.75 37.00
Subtotal (Total Children Is Unduplicated) 130 270.25 9999.25 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 10 10.00 485.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 51 51.00 2473.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 8 8.00 388.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 23 23.00 1115.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 72 73.00 3540.50 48.50
Subtotal (Total Children Is Unduplicated) 137 169.00 8202.50 48.54
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 30 38.75 1937.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 5.50 275.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 1.00 25.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 1.75 87.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 1.00 25.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.00 50.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 1.75 87.50 50.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 93 6469.00 161725.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 40 1545.00 38625.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 773 6776.50 338825.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 176 1014.25 68847.29 67.88
PHY-97110-PT SESSION BY LICENSED PT 104 614.00 41678.32 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 219 1020.00 69237.60 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 22 78.00 4236.96 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 13 24.00 316.80 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 774 159118 79559.00 0.50
Subtotal (Total Children Is Unduplicated) 989 176711 805592.79 4.56
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Total 177149.75 823794.54 4.65
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Number of Children (Unduplicated) With at Least One Service 999
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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 87 39.00 1443.00 0.00
P 3300 160596.25 231531.62 231317.42
D 3 2.50 92.50 92.50
S 0 0.00 0.00 0.00
H 1972 7379.00 325453.82 325154.40
T 0 0.00 0.00 0.00
1180 9133.00 265273.60 300.00
Other 0 0.00 0.00 0.00
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Total 6542 177149.75 823794.54 556864.32