CMS/EIP Fiscal Report Center: 09
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 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
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 6 7.00 380.00 54.29
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 158 1152.00 57600.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 101 649.50 44088.06 67.88
PHY-97110-PT SESSION BY LICENSED PT 114 619.00 42017.72 67.88
PHY-97110HM-PT SESSION BY PT ASST 5 43.00 2335.76 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 144 855.75 58088.31 67.88
Subtotal (Total Children Is Unduplicated) 367 3319.25 204129.85 61.50
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Total 3326.25 204509.85 61.48
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Number of Children (Unduplicated) With at Least One Service 368
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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 1 1.00 67.88 67.88
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
1192 3325.25 204441.97 0.00
Other 0 0.00 0.00 0.00
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Total 1193 3326.25 204509.85 67.88