CMS/EIP Fiscal Report Center: 09
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
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.00 119.60 119.60
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 14.50 804.75 55.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 15 25.50 1488.85 58.39
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 179 1331.00 66550.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 109 737.75 50078.47 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 4.75 258.02 54.32
PHY-97110-PT SESSION BY LICENSED PT 119 690.50 46871.14 67.88
PHY-97110HM-PT SESSION BY PT ASST 9 43.75 2376.50 54.32
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 146 963.25 65385.41 67.88
Subtotal (Total Children Is Unduplicated) 400 3773.00 231556.98 61.37
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Total 3798.50 233045.83 61.35
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Number of Children (Unduplicated) With at Least One Service 406
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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 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
1446 3798.50 233045.83 0.00
Other 0 0.00 0.00 0.00
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Total 1446 3798.50 233045.83 0.00