CMS/EIP Fiscal Report Center: 52
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:OTHER
Eligibility Filter:Program Patients
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 2 2.00 97.00 48.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 13.50 630.50 46.70
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.00 145.50 48.50
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 18 24.50 1164.00 47.51
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EI Services,Class #03
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 1.50 75.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 2 0.75 50.91 67.88
PHY-97110-PT SESSION BY LICENSED PT 4 4.25 288.49 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 33.94 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 14.75 1001.23 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 36 1329.46 664.73 0.50
Subtotal (Total Children Is Unduplicated) 49 1351.21 2114.30 1.56
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Total 1375.71 3278.30 2.38
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Number of Children (Unduplicated) With at Least One Service 67
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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
91 1375.71 3278.30 0.00
Other 0 0.00 0.00 0.00
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Total 91 1375.71 3278.30 0.00