CMS/EIP Fiscal Report Center: 57
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 5 5.00 242.50 48.50
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 3 3.00 150.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 2.00 50.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.00 100.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.50 37.50 25.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 9 460.00 4140.00 9.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.00 200.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 5 9.00 610.92 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 1.50 101.82 67.88
PHY-97110-PT SESSION BY LICENSED PT 9 25.50 1730.94 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 20 32.25 2189.13 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.50 33.00 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 24 1494.00 747.00 0.50
Subtotal (Total Children Is Unduplicated) 60 2037.25 10090.31 4.95
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Total 2042.25 10332.81 5.06
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Number of Children (Unduplicated) With at Least One Service 61
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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 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
57 1587.25 6404.97 373.34
Other 52 455.00 3927.84 4064.54
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Total 109 2042.25 10332.81 4437.88