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: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 19 26.00 1950.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 7.50 562.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 10.50 787.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.50 262.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.00 388.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 20 20.00 970.00 48.50
Subtotal (Total Children Is Unduplicated) 57 80.50 5163.00 64.14
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 38 218.25 10912.50 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 16.00 800.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 45 224.25 15222.09 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 18.00 977.76 54.32
PHY-97110-PT SESSION BY LICENSED PT 55 269.39 18285.90 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 6.00 300.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 105 559.45 37974.98 67.88
Subtotal (Total Children Is Unduplicated) 170 1311.34 84473.23 64.42
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Total 1391.84 89636.23 64.40
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Number of Children (Unduplicated) With at Least One Service 195
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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 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
576 1391.84 89636.23 0.00
Other 0 0.00 0.00 0.00
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Total 576 1391.84 89636.23 0.00