CMS/EIP Fiscal Report Center: 52
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
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.50 161.00 64.40
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 12 14.00 679.00 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 10 10.00 485.00 48.50
Subtotal (Total Children Is Unduplicated) 33 38.50 1907.00 49.53
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 19 157.25 7862.50 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 9.00 450.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 43 286.50 19447.62 67.88
PHY-97110-PT SESSION BY LICENSED PT 46 294.25 19973.69 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 5.75 312.34 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 2.50 125.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 69 389.71 26452.35 67.88
Subtotal (Total Children Is Unduplicated) 120 1144.96 74623.50 65.18
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Total 1183.46 76530.50 64.67
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Number of Children (Unduplicated) With at Least One Service 130
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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 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
482 1183.46 76530.50 0.00
Other 0 0.00 0.00 0.00
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Total 482 1183.46 76530.50 0.00