CMS/EIP Fiscal Report Center: 57
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
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
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 11 12.00 582.00 48.50
Subtotal (Total Children Is Unduplicated) 18 21.00 1018.50 48.50
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EI Services,Class #03
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 10.00 500.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 40 139.00 9435.32 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 2.50 135.80 54.32
PHY-97110-PT SESSION BY LICENSED PT 46 182.00 12354.16 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 3.00 162.96 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 65 188.50 12795.38 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.50 46.20 13.20
Subtotal (Total Children Is Unduplicated) 110 529.50 35479.82 67.01
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Total 550.50 36498.32 66.30
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Number of Children (Unduplicated) With at Least One Service 115
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Center 57
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 1 1.50 101.82 101.82
H 0 0.00 0.00 0.00
T 2 2.50 151.82 151.82
263 546.50 36244.68 28197.16
Other 0 0.00 0.00 0.00
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Total 266 550.50 36498.32 28450.80