CMS/EIP Fiscal Report Center: 55
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
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 46.80 46.80
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 30.00 2250.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 22.00 1650.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 14.50 1087.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 32.50 1748.25 53.79
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.00 242.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 8.00 388.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.00 388.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 11 11.00 533.50 48.50
Subtotal (Total Children Is Unduplicated) 65 134.50 8495.55 63.16
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 35 226.00 11300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 61 257.75 17496.07 67.88
OCCT-97530HM-OT SESSION BY OT ASST 6 58.25 3164.14 54.32
PHY-97110-PT SESSION BY LICENSED PT 37 171.00 11593.92 67.80
PHY-97110HM-PT SESSION BY PT ASST 7 22.50 1222.20 54.32
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 105 544.75 36977.63 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 3.00 162.96 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 13.20 13.20
Subtotal (Total Children Is Unduplicated) 167 1286.25 81967.56 63.73
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Total 1420.75 90463.11 63.67
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Number of Children (Unduplicated) With at Least One Service 197
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Center 55
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 1.50 112.50 112.50
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
1858 1419.25 90350.61 0.00
Other 0 0.00 0.00 0.00
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Total 1859 1420.75 90463.11 112.50