CMS/EIP Fiscal Report Center: 05
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
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 19.00 1425.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.00 450.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 18 22.00 1650.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 9.50 527.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 5.50 412.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 9 9.00 436.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 9.00 436.50 48.50
Subtotal (Total Children Is Unduplicated) 55 89.00 5827.25 65.47
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 104 309.25 15462.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 38 99.25 6737.09 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 2.50 135.80 54.32
PHY-97110-PT SESSION BY LICENSED PT 76 289.00 19617.32 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 27.16 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 79 258.00 17513.04 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 6.00 325.92 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 7 21.00 277.20 13.20
Subtotal (Total Children Is Unduplicated) 175 985.50 60096.03 60.98
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Total 1074.50 65923.28 61.35
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Number of Children (Unduplicated) With at Least One Service 199
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Center 05
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 1 1.00 75.00 75.00
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
1385 1073.50 65848.28 0.00
Other 0 0.00 0.00 0.00
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Total 1386 1074.50 65923.28 75.00