CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2008 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
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 2 2.00 225.00 112.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 5.00 348.50 69.70
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 9.50 712.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.00 242.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 54 60.00 2910.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 8 11.00 533.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 42 45.00 2182.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 55 59.00 2846.94 48.25
Subtotal (Total Children Is Unduplicated) 136 199.50 10173.23 50.99
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 62 784.00 39200.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 32.00 1600.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 92 1153.00 78075.80 67.72
PHY-97110-PT SESSION BY LICENSED PT 97 1288.60 87468.81 67.88
PHY-97110HM-PT SESSION BY PT ASST 3 24.25 1317.26 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 2.50 125.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 155 1631.72 110747.18 67.87
Subtotal (Total Children Is Unduplicated) 270 4916.07 318534.05 64.79
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Total 5115.57 328707.28 64.26
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Number of Children (Unduplicated) With at Least One Service 295
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Center 52
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 1 1.00 48.50 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
2173 5114.57 328658.78 0.00
Other 0 0.00 0.00 0.00
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Total 2174 5115.57 328707.28 0.00