CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 1 1.50 55.50 37.00
Subtotal (Total Children Is Unduplicated) 1 1.50 55.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 8.50 637.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 45.00 3375.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 29.50 1637.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 57 98.00 6533.50 66.67
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.00 523.80 261.90
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 75 283.00 14150.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 3 2.50 167.76 67.10
OCCT-97530HM-OT SESSION BY OT ASST 3 7.00 380.24 54.32
PHY-97110-PT SESSION BY LICENSED PT 19 65.75 4463.11 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 7.00 380.24 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 80 402.25 27091.42 67.35
Subtotal (Total Children Is Unduplicated) 167 769.50 47156.57 61.28
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Total 869.00 53745.57 61.85
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Number of Children (Unduplicated) With at Least One Service 211
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Center 01
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 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
370 859.00 53109.69 0.00
Other 8 10.00 635.88 0.00
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Total 378 869.00 53745.57 0.00