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: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 66 127.75 4726.75 37.00
Subtotal (Total Children Is Unduplicated) 66 127.75 4726.75 37.00
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Screening, Eval, and Assessment,Class #02
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 4.00 194.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 14.00 679.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 12 12.00 582.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 30 30.00 1455.00 48.50
Subtotal (Total Children Is Unduplicated) 52 65.00 3152.50 48.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 567 4856.50 242825.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 60 337.50 22909.50 67.88
PHY-97110-PT SESSION BY LICENSED PT 49 238.00 16155.44 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 82 380.75 25845.31 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 15.50 841.96 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 2 10.00 132.00 13.20
Subtotal (Total Children Is Unduplicated) 635 5838.25 308709.21 52.88
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Total 6031.00 316588.46 52.49
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Number of Children (Unduplicated) With at Least One Service 673
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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 164 90.75 3383.75 3383.75
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 1684 5519.00 286753.58 286752.92
T 0 0.00 0.00 0.00
202 382.25 25008.13 300.00
Other 0 0.00 0.00 0.00
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Total 2137 6031.00 316588.46 290436.67