CMS/EIP Fiscal Report Center: 55
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
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 8.00 400.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 3 3.25 162.50 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 45.89 3441.49 74.99
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 24.74 1855.24 74.99
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 35.00 1942.50 55.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 0.17 8.21 48.29
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 13.00 630.50 48.50
Subtotal (Total Children Is Unduplicated) 67 133.05 8665.44 65.13
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 4.00 2431.55 607.89
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 1.00 50.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.50 125.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 1.00 50.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 16 97.75 4887.50 50.00
INTR-INTR-INTERPRETER 1 16.00 708.00 44.25
OCCT-97530-OT SESSION BY LICENSED OT 30 130.47 8854.41 67.87
OCCT-97530HM-OT SESSION BY OT ASST 7 39.00 2118.48 54.32
PHY-97110-PT SESSION BY LICENSED PT 29 66.96 4543.73 67.86
PHY-97110HM-PT SESSION BY PT ASST 7 20.96 1132.86 54.05
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 126 619.53 42053.47 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 362 67987.0 51898.09 0.76
Subtotal (Total Children Is Unduplicated) 389 68988.2 118953.09 1.72
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Total 69121.22 127618.53 1.85
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Number of Children (Unduplicated) With at Least One Service 408
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Center 55
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 2527 38501.10 72227.23 72227.23
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 963 15636.10 28611.26 28611.26
985 14984.02 26780.04 0.00
Other 0 0.00 0.00 0.00
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Total 4475 69121.22 127618.53 100838.49