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
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 44 66.50 2460.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 56 76.00 2812.00 37.00
Subtotal (Total Children Is Unduplicated) 97 142.50 5272.50 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 6 6.00 291.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 19 19.00 921.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 11 11.00 533.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 26 26.00 1261.00 48.50
Subtotal (Total Children Is Unduplicated) 56 69.00 3352.50 48.59
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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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 213 1635.00 81750.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 73 411.75 27949.59 67.88
PHY-97110-PT SESSION BY LICENSED PT 36 188.00 12761.44 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 77 310.50 21076.74 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 9 36.00 1955.52 54.32
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 774 159118 79559.00 0.50
Subtotal (Total Children Is Unduplicated) 851 161751 227594.11 1.41
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Total 161962.50 236219.11 1.46
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Number of Children (Unduplicated) With at Least One Service 908
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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 3136 160505.50 228147.87 227933.67
D 3 2.50 92.50 92.50
S 0 0.00 0.00 0.00
H 30 1314.50 2798.74 2798.74
T 0 0.00 0.00 0.00
321 140.00 5180.00 0.00
Other 0 0.00 0.00 0.00
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Total 3490 161962.50 236219.11 230824.91