CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 3.00 225.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 4.50 337.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 5.00 277.50 55.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 12 15.50 985.50 63.58
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 53 252.00 12600.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 18 35.25 2392.77 67.88
PHY-97110-PT SESSION BY LICENSED PT 35 103.50 7025.58 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 3.00 162.96 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 42 91.00 6177.08 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 3 5.00 66.00 13.20
Subtotal (Total Children Is Unduplicated) 98 489.75 28424.39 58.04
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Total 505.25 29409.89 58.21
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Number of Children (Unduplicated) With at Least One Service 102
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Center 05
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
562 505.25 29409.89 0.00
Other 0 0.00 0.00 0.00
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Total 562 505.25 29409.89 0.00