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
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
EXIT-EXIT-TRANSITION ASSESSMENT 2 2.00 100.00 50.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 28 28.00 1400.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 5.50 242.50 44.09
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 2.89 115.50 39.97
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.00 242.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 82.44 41.22
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 49 53.89 2634.94 48.89
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 18 19.25 962.50 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
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 4 2.00 100.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 29 182.55 9127.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 14 59.41 4032.51 67.88
PHY-97110-PT SESSION BY LICENSED PT 33 121.61 8253.08 67.87
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 70 463.97 31493.90 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 359 68509.0 34254.50 0.50
Subtotal (Total Children Is Unduplicated) 381 69360.5 88323.99 1.27
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Total 69414.43 90958.93 1.31
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Number of Children (Unduplicated) With at Least One Service 389
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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 1 26.00 13.00 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 1005 41424.71 56077.47 55970.97
535 27963.72 34868.46 0.00
Other 0 0.00 0.00 0.00
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Total 1541 69414.43 90958.93 55970.97