CMS/EIP Fiscal Report Center: 09
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 Page: 1
Agency Filter:EXT
Payclass Filters:GR
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 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 11.00 825.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.00 450.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 14.00 1009.34 72.10
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 13 35.00 2532.84 72.37
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.00 1145.50 1145.50
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 30 36.00 1800.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 30 18.50 925.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 15 37.00 1850.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 25 24.25 1212.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 185 1596.75 78777.50 49.34
OCCT-97530-OT SESSION BY LICENSED OT 172 1195.25 76983.97 64.41
PHY-97110-PT SESSION BY LICENSED PT 137 776.50 49137.36 63.28
PHY-97110HM-PT SESSION BY PT ASST 2 1.00 54.32 54.32
SENS-V5264-EARMOLD 5 10.00 187.20 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 409 3017.75 203054.61 67.29
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 659 177570 88785.00 0.50
Subtotal (Total Children Is Unduplicated) 888 184285 503962.96 2.73
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Total 184320.00 506495.80 2.75
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Number of Children (Unduplicated) With at Least One Service 894
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Center 09
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 2647 111267.00 292367.86 292367.86
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 1726 70183.00 185440.60 185440.60
260 2870.00 28687.34 1959.75
Other 0 0.00 0.00 0.00
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Total 4633 184320.00 506495.80 479768.21