CMS/EIP Fiscal Report Center: 05
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 13.41 892.39 66.55
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 5.24 393.18 75.03
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 7.23 542.15 74.99
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.00 333.00 55.50
OCTH-97003-OT EVAL BY LICENSED OT, 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) 15 33.88 2257.72 66.64
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.00 50.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 19.75 987.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 39 135.22 9086.98 67.20
OCCT-97530HM-OT SESSION BY OT ASST 1 4.00 217.28 54.32
PHY-97110-PT SESSION BY LICENSED PT 50 165.00 11200.20 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 79 264.26 17543.22 66.39
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 0.50 27.16 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 2 3.00 39.60 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 30.00 15.00 0.50
Subtotal (Total Children Is Unduplicated) 123 623.73 39216.94 62.87
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Total 657.61 41474.66 63.07
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Number of Children (Unduplicated) With at Least One Service 130
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Center 05
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 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1099 657.61 41474.66 0.00
Other 0 0.00 0.00 0.00
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Total 1099 657.61 41474.66 0.00