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: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
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 3.00 187.50 62.50
EXIT-EXIT-TRANSITION ASSESSMENT 2 3.00 225.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 30.30 2272.44 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 15.50 1162.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.83 212.31 75.02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.50 222.00 40.36
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 4.66 226.20 48.54
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 0.98 47.36 48.33
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 4.64 225.00 48.49
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 6.93 336.00 48.48
Subtotal (Total Children Is Unduplicated) 47 77.34 5116.31 66.15
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 6 6.00 300.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 2.00 100.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 12.50 625.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 46 131.91 8886.52 67.37
OCCT-97530HM-OT SESSION BY OT ASST 2 3.75 203.70 54.32
PHY-97110-PT SESSION BY LICENSED PT 32 94.37 6396.13 67.78
PHY-97110HM-PT SESSION BY PT ASST 4 6.50 353.08 54.32
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 72 237.89 16149.94 67.89
Subtotal (Total Children Is Unduplicated) 118 496.92 33051.81 66.51
----------------------------------------------------------------------------------------------------------------
Total 574.26 38168.12 66.46
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 137
----------------------------------------------------------------------------------------------------------------
Center 55
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 7 6.00 428.64 428.64
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 19 15.50 828.64 828.64
813 552.76 36910.84 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 839 574.26 38168.12 1257.28