CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:TPIN
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-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 39.00 2925.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 31.00 1692.75 54.60
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 9.00 675.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 147.40 49.13
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 7.00 339.50 48.50
Subtotal (Total Children Is Unduplicated) 43 93.00 6054.65 65.10
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 1.75 87.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.75 37.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 15 53.91 2708.38 50.24
OCCT-97530-OT SESSION BY LICENSED OT 5 24.50 1663.06 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 1.00 67.88 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 129.64 8801.55 67.89
Subtotal (Total Children Is Unduplicated) 53 211.55 13365.87 63.18
----------------------------------------------------------------------------------------------------------------
Total 304.55 19420.52 63.77
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 86
----------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
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 0.89 60.41 60.41
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 47 75.50 4636.65 0.00
T 0 0.00 0.00 0.00
125 228.16 14723.46 173.78
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 173 304.55 19420.52 234.19