CMS/EIP Fiscal Report Center: 51
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EXT
Payclass Filters:MED
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 2 3.00 225.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 30.00 2250.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 13.00 975.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.50 262.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 6.00 333.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 52 63.00 4651.50 73.83
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 7 7.00 339.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 13 13.00 630.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 7.00 339.50 48.50
Subtotal (Total Children Is Unduplicated) 83 148.50 10178.50 68.54
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 12.00 881.04 73.42
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 118 794.50 39725.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 55 321.25 21806.45 67.88
OCCT-97530HM-OT SESSION BY OT ASST 11 32.75 1778.98 54.32
PHY-97110-PT SESSION BY LICENSED PT 66 352.00 23741.21 67.45
PHY-97110HM-PT SESSION BY PT ASST 19 110.00 5975.20 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 65 423.00 28381.34 67.10
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.75 23.10 13.20
Subtotal (Total Children Is Unduplicated) 198 2047.25 122312.32 59.74
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Total 2195.75 132490.82 60.34
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Number of Children (Unduplicated) With at Least One Service 242
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Center 51
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
882 2195.75 132490.82 0.00
Other 0 0.00 0.00 0.00
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Total 882 2195.75 132490.82 0.00