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
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
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 3.00 150.00 50.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 42.13 3160.05 75.01
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 20.50 1537.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 10.50 787.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 15.50 860.25 55.50
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 5.80 281.00 48.45
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.00 339.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.00 291.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 14 14.00 679.00 48.50
Subtotal (Total Children Is Unduplicated) 69 127.93 8295.30 64.84
----------------------------------------------------------------------------------------------------------------
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 25 214.25 10712.50 50.00
INTR-INTR-INTERPRETER 1 2.00 84.00 42.00
OCCT-97530-OT SESSION BY LICENSED OT 59 229.66 15584.31 67.86
OCCT-97530HM-OT SESSION BY OT ASST 3 4.50 231.48 51.44
PHY-97110-PT SESSION BY LICENSED PT 36 176.36 11918.58 67.58
PHY-97110HM-PT SESSION BY PT ASST 6 19.50 1059.24 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 136 790.33 51500.19 65.16
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 238 49088.0 37972.10 0.77
Subtotal (Total Children Is Unduplicated) 293 50614.1 133537.40 2.64
----------------------------------------------------------------------------------------------------------------
Total 50742.03 141832.70 2.80
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 326
----------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
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
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 4471 50742.03 141832.70 141832.70