CMS/EIP Fiscal Report Center: 52
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Agency Filter:EXT
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
EXIT-EXIT-TRANSITION ASSESSMENT 2 2.00 100.00 50.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 28 29.00 1448.50 49.95
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 39 47.50 2269.00 47.77
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 5.00 242.50 48.50
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 18.00 888.50 49.36
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 8.50 637.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 28 28.00 1358.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 6.00 276.44 46.07
PSTH-97001-EVAL BY LICENSED PT, INITIAL 14 15.00 727.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 28 28.00 1358.00 48.50
Subtotal (Total Children Is Unduplicated) 129 187.00 9305.94 49.76
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 19 20.25 1012.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.50 12.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.25 12.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 2 1.00 25.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 5 2.50 125.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 41 194.00 5880.00 30.31
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 79 512.00 24300.00 47.46
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 6.00 300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 82 558.25 37894.01 67.88
PHY-97110-PT SESSION BY LICENSED PT 129 625.25 42480.33 67.94
PHY-97110HM-PT SESSION BY PT ASST 3 6.25 346.28 55.40
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.50 75.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 247 1354.75 91960.43 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 359 69637.0 34818.50 0.50
Subtotal (Total Children Is Unduplicated) 407 72920.8 239298.30 3.28
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Total 73107.75 248604.24 3.40
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Number of Children (Unduplicated) With at Least One Service 426
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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 2 28.00 148.76 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 1005 41424.71 56077.47 55970.97
1768 31655.04 192378.01 0.00
Other 0 0.00 0.00 0.00
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Total 2775 73107.75 248604.24 55970.97