CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:OTHER
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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 13.00 975.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 5.00 375.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 6.00 450.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.00 222.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 9.00 675.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 16 41.00 2944.00 71.80
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 2.25 112.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 5 4.00 200.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.75 18.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 9 8.25 412.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 6 9.00 250.00 27.78
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 5.00 250.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 17 20.00 1000.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 4 1.25 31.25 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 1.00 25.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 16 111.50 5575.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 6 47.25 3207.33 67.88
PHY-97110-PT SESSION BY LICENSED PT 7 24.25 1632.53 67.32
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 27.16 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 67.00 4547.96 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.00 26.40 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 23 15227.0 7584.00 0.50
Subtotal (Total Children Is Unduplicated) 23 15531.0 24900.38 1.60
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Total 15572.00 27844.38 1.79
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Number of Children (Unduplicated) With at Least One Service 23
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Center 05
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
787 15572.00 27844.38 0.00
Other 0 0.00 0.00 0.00
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Total 787 15572.00 27844.38 0.00