CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 6.08 294.88 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 16 16.08 779.88 48.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 12 35.00 1750.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 29 130.78 8736.66 66.80
OCCT-97530HM-OT SESSION BY OT ASST 4 5.50 298.76 54.32
PHY-97110-PT SESSION BY LICENSED PT 19 79.50 5353.98 67.35
PHY-97110HM-PT SESSION BY PT ASST 1 6.00 325.92 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 25 73.37 4678.27 63.76
SPL-92508-GROUP SPL SESSION PER CHILD 3 5.00 66.00 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 30.00 15.00 0.50
Subtotal (Total Children Is Unduplicated) 74 365.15 21224.59 58.13
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Total 381.23 22004.47 57.72
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Number of Children (Unduplicated) With at Least One Service 78
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Center 04
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 9 56.00 1545.94 1545.94
D 8 17.00 1120.06 1153.96
S 0 0.00 0.00 0.00
H 149 308.23 19338.47 19501.04
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 166 381.23 22004.47 22200.94