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: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
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 3.00 225.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 14.00 679.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.00 339.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 11 11.00 533.50 48.50
Subtotal (Total Children Is Unduplicated) 36 39.50 2035.00 51.52
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 24 144.25 7212.50 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 6.00 300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 43 323.50 21959.18 67.88
PHY-97110-PT SESSION BY LICENSED PT 60 322.50 21891.30 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 5.75 312.34 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 76 418.25 28390.81 67.88
Subtotal (Total Children Is Unduplicated) 137 1220.25 80066.13 65.61
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Total 1259.75 82101.13 65.17
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Number of Children (Unduplicated) With at Least One Service 144
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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
524 1259.75 82101.13 0.00
Other 0 0.00 0.00 0.00
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Total 524 1259.75 82101.13 0.00