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: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
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.00 50.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.00 97.00 48.50
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.00 97.00 48.50
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.00 97.00 48.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 2.00 97.00 48.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 18.50 824.50 44.57
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 8.00 339.50 42.44
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.50 145.50 41.57
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.50 187.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 7.00 339.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 9.00 436.50 48.50
Subtotal (Total Children Is Unduplicated) 47 62.50 2953.50 47.26
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EI Services,Class #03
AUD-HA_FUP-AUDIOLOGY SERVICES 2 1.90 94.84 49.92
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 20 69.84 3541.79 50.71
OCCT-97530-OT SESSION BY LICENSED OT 33 179.11 12158.21 67.88
PHY-97110-PT SESSION BY LICENSED PT 45 170.25 11702.05 68.73
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 113 509.94 34683.33 68.01
Subtotal (Total Children Is Unduplicated) 170 932.04 62234.54 66.77
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Total 994.54 65188.04 65.55
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Number of Children (Unduplicated) With at Least One Service 181
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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
542 994.54 65188.04 0.00
Other 0 0.00 0.00 0.00
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Total 542 994.54 65188.04 0.00