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: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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 9.00 675.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.50 337.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 16.00 1200.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.50 305.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.00 300.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 10 10.00 485.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 12 12.00 582.00 48.50
Subtotal (Total Children Is Unduplicated) 46 68.00 4330.25 63.68
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 48 290.00 14450.00 49.83
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 20.00 1000.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 48 241.00 16359.08 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 9.00 488.88 54.32
PHY-97110-PT SESSION BY LICENSED PT 46 290.20 19647.38 67.70
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 13.00 650.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 120 711.50 48296.62 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 4 36.25 478.50 13.20
Subtotal (Total Children Is Unduplicated) 181 1610.95 101370.46 62.93
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Total 1678.95 105700.71 62.96
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Number of Children (Unduplicated) With at Least One Service 198
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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
681 1678.95 105700.71 0.00
Other 0 0.00 0.00 0.00
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Total 681 1678.95 105700.71 0.00