CMS/EIP Fiscal Report Center: 55
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
EVAL-EVAL-DEVELOPMENTAL EVALUATION 8 13.00 650.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.00 525.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 109.50 8137.50 74.32
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 37 65.00 4875.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 21.00 1575.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 46.50 2580.75 55.50
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 10 10.00 485.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 17 18.00 873.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 18 18.00 873.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 26 26.00 1261.00 48.50
Subtotal (Total Children Is Unduplicated) 147 343.50 22363.75 65.11
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.50 75.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 11 88.00 4400.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 42 295.25 14762.50 50.00
INTR-INTR-INTERPRETER 1 2.00 84.00 42.00
OCCT-97530-OT SESSION BY LICENSED OT 139 673.60 45642.60 67.76
OCCT-97530HM-OT SESSION BY OT ASST 9 39.25 2119.10 53.99
PHY-97110-PT SESSION BY LICENSED PT 84 359.06 24320.07 67.73
PHY-97110HM-PT SESSION BY PT ASST 15 34.94 1898.46 54.33
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 228 1331.72 88244.83 66.26
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 13.20 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 238 49088.0 37972.10 0.77
Subtotal (Total Children Is Unduplicated) 334 51914.3 219531.86 4.23
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Total 52257.82 241895.61 4.63
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Number of Children (Unduplicated) With at Least One Service 405
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Center 55
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 4471 50742.03 141832.70 141832.70
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
2095 1515.79 100062.91 0.00
Other 0 0.00 0.00 0.00
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Total 6566 52257.82 241895.61 141832.70