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:TPIN
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 6 10.00 500.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 34.37 2577.45 74.99
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 17.00 1275.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.50 337.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.00 333.00 55.50
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 3.20 155.50 48.59
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 8 8.00 388.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.00 339.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 53 99.57 6406.45 64.34
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 7.00 350.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 53 218.44 14805.59 67.78
OCCT-97530HM-OT SESSION BY OT ASST 2 1.75 95.06 54.32
PHY-97110-PT SESSION BY LICENSED PT 29 99.70 6767.45 67.88
PHY-97110HM-PT SESSION BY PT ASST 3 3.94 214.54 54.45
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 56 246.89 16753.98 67.86
Subtotal (Total Children Is Unduplicated) 95 577.72 38986.62 67.48
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Total 677.29 45393.07 67.02
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Number of Children (Unduplicated) With at Least One Service 123
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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 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
1043 677.29 45393.07 0.00
Other 0 0.00 0.00 0.00
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Total 1043 677.29 45393.07 0.00