CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
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 2 3.00 225.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.50 262.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 6.51 188.00 28.88
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 0.66 32.00 48.48
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 12 16.67 879.50 52.76
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 30 69.36 4588.02 66.15
PHY-97110-PT SESSION BY LICENSED PT 44 199.34 11474.57 57.56
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 57 185.48 12235.14 65.96
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.00 39.60 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 321.00 160.50 0.50
Subtotal (Total Children Is Unduplicated) 93 778.18 28497.83 36.62
----------------------------------------------------------------------------------------------------------------
Total 794.85 29377.33 36.96
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 100
----------------------------------------------------------------------------------------------------------------
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
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
762 794.85 29377.33 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 762 794.85 29377.33 0.00