CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.00 50.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 17 18.50 850.00 45.95
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.50 273.50 60.78
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.50 198.50 56.71
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.00 100.00 50.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.00 291.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.00 242.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 42 51.00 2634.00 51.65
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 51 49.75 2487.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 6 5.00 250.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.25 6.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.00 100.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.50 12.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 13 6.75 337.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 5 1.75 43.75 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 11 11.75 587.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.50 12.50 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 18 67.80 3390.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 11.00 550.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 42 212.51 14421.20 67.86
PHY-97110-PT SESSION BY LICENSED PT 33 163.89 11122.66 67.87
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.50 75.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 117 554.58 37641.09 67.87
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 392 88573.0 44286.50 0.50
Subtotal (Total Children Is Unduplicated) 418 89662.5 115323.95 1.29
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Total 89713.53 117957.95 1.31
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Number of Children (Unduplicated) With at Least One Service 426
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Center 52
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 741 37282.98 50660.90 50660.90
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
979 52430.55 67297.05 0.00
Other 0 0.00 0.00 0.00
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Total 1720 89713.53 117957.95 50660.90