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: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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 11.84 700.24 59.14
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 4.50 318.31 70.74
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 13 18.34 1115.55 60.83
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 21 79.55 3769.10 47.38
PHY-97110-PT SESSION BY LICENSED PT 39 159.02 7432.06 46.74
PHY-97110HM-PT SESSION BY PT ASST 1 2.00 108.64 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 36 112.49 6465.62 57.48
SPL-92508-GROUP SPL SESSION PER CHILD 4 6.03 86.75 14.39
Subtotal (Total Children Is Unduplicated) 79 361.09 17962.17 49.74
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Total 379.43 19077.72 50.28
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Number of Children (Unduplicated) With at Least One Service 86
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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
522 379.43 19077.72 0.00
Other 0 0.00 0.00 0.00
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Total 522 379.43 19077.72 0.00