CMS/EIP Fiscal Report Center: 51
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.00 150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 13 15.00 857.25 57.15
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 6.00 300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 18 58.25 3954.01 67.88
OCCT-97530HM-OT SESSION BY OT ASST 3 14.25 814.74 57.17
PHY-97110-PT SESSION BY LICENSED PT 30 123.25 8230.61 66.78
PHY-97110HM-PT SESSION BY PT ASST 3 7.00 400.58 57.23
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 80.75 5481.31 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 3 4.00 52.80 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 37.00 18.50 0.50
Subtotal (Total Children Is Unduplicated) 53 330.50 19252.55 58.25
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Total 345.50 20109.80 58.20
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Number of Children (Unduplicated) With at Least One Service 57
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Center 51
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
144 345.50 20109.80 0.00
Other 0 0.00 0.00 0.00
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Total 144 345.50 20109.80 0.00