CMS/EIP Fiscal Report Center: 52
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 2 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 48.50 48.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 4.00 220.50 55.13
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.00 300.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 11.00 772.00 70.18
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.50 262.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 23 24.00 1164.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.00 339.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 14 14.00 679.00 48.50
Subtotal (Total Children Is Unduplicated) 53 70.50 3936.00 55.83
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 34 215.25 10762.50 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 10.00 500.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 53 340.25 23096.17 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 1.50 81.48 54.32
PHY-97110-PT SESSION BY LICENSED PT 55 300.50 20397.94 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.50 81.48 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 97 423.25 28709.87 67.83
SPL-92508-GROUP SPL SESSION PER CHILD 2 10.50 138.60 13.20
Subtotal (Total Children Is Unduplicated) 177 1307.75 84018.04 64.25
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Total 1378.25 87954.04 63.82
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Number of Children (Unduplicated) With at Least One Service 190
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Center 52
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
603 1378.25 87954.04 0.00
Other 0 0.00 0.00 0.00
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Total 603 1378.25 87954.04 0.00