CMS/EIP Fiscal Report Center: 09
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.00 600.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 12 16.00 1069.00 66.81
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 115 990.00 49440.00 49.94
OCCT-97530-OT SESSION BY LICENSED OT 100 600.00 40728.00 67.88
PHY-97110-PT SESSION BY LICENSED PT 114 670.25 45391.31 67.72
PHY-97110HM-PT SESSION BY PT ASST 6 49.00 2661.68 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 141 819.75 55644.63 67.88
Subtotal (Total Children Is Unduplicated) 327 3129.00 193865.62 61.96
----------------------------------------------------------------------------------------------------------------
Total 3145.00 194934.62 61.98
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 334
----------------------------------------------------------------------------------------------------------------
Center 09
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 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
1162 3145.00 194934.62 105.26
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1162 3145.00 194934.62 105.26