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:EIP DEI DEIP
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
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.25 62.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 32 57.00 4275.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.50 262.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 5.50 412.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 54.50 3024.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 13.50 1012.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 15 15.00 727.50 48.50
Subtotal (Total Children Is Unduplicated) 71 159.25 10283.75 64.58
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EI Services,Class #03
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 12.50 625.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 30 111.50 5575.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 9 53.25 3614.61 67.88
PHY-97110-PT SESSION BY LICENSED PT 3 4.50 305.46 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 33 143.00 9706.84 67.88
Subtotal (Total Children Is Unduplicated) 68 325.75 19876.91 61.02
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Total 485.00 30160.66 62.19
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Number of Children (Unduplicated) With at Least One Service 121
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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 78 143.50 9261.49 0.00
T 0 0.00 0.00 0.00
181 341.50 20899.17 0.00
Other 0 0.00 0.00 0.00
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Total 259 485.00 30160.66 0.00