CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 3 3.00 150.00 50.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 10 11.00 533.25 48.48
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 5.50 412.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 8.50 637.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.00 339.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 22 21.80 1056.93 48.48
Subtotal (Total Children Is Unduplicated) 54 60.80 3323.68 54.67
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EI Services,Class #03
AUD-HA_FUP-AUDIOLOGY SERVICES 2 2.00 76.92 38.46
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 30 31.00 1550.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 14 8.00 400.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 4 1.75 43.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 6 2.50 125.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 8 3.75 93.75 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 3.00 150.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 10 4.25 106.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 11 9.25 462.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 10 4.00 100.00 25.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 5 12.00 84.00 7.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 11 43.50 2175.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 6.00 300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 35 180.04 12216.12 67.85
OCCT-97530HM-OT SESSION BY OT ASST 5 63.28 3437.22 54.32
PHY-97110-PT SESSION BY LICENSED PT 38 243.62 16531.94 67.86
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 4.00 200.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 129 687.05 46627.98 67.87
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 413 100163 50081.50 0.50
Subtotal (Total Children Is Unduplicated) 431 101472 134761.93 1.33
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Total 101532.79 138085.61 1.36
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Number of Children (Unduplicated) With at Least One Service 436
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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 706 36888.57 47649.07 47649.07
D 1 2.00 100.00 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
1343 64642.22 90336.54 0.00
Other 0 0.00 0.00 0.00
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Total 2050 101532.79 138085.61 47649.07