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:OTHER
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 2 2.00 97.00 48.50
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 4.00 200.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 2.00 50.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 4 4.00 200.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.00 25.00 25.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 8 288.00 3012.00 10.46
OCCT-97530-OT SESSION BY LICENSED OT 3 5.00 339.40 67.88
PHY-97110-PT SESSION BY LICENSED PT 3 6.00 407.28 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 16 40.00 2715.20 67.88
TRAN-TRAN-FAMILY TRANSPORTATION 30 1134.00 16290.00 14.37
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 30 1104.00 784.00 0.71
Subtotal (Total Children Is Unduplicated) 58 2588.00 24022.88 9.28
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Total 2590.00 24119.88 9.31
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Number of Children (Unduplicated) With at Least One Service 58
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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 3 122.00 160.00 160.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
84 2209.00 20533.92 0.00
Other 40 259.00 3425.96 3527.78
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Total 127 2590.00 24119.88 3687.78