CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:OTHER
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
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 30 39.50 2803.50 70.97
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 6.00 242.50 40.42
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.00 123.50 61.75
Subtotal (Total Children Is Unduplicated) 37 49.50 3266.50 65.99
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.00 1100.00 550.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 6 8.00 400.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.25 12.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 0.50 12.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 2.00 100.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 2.00 100.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 0.25 12.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 0.50 12.50 25.00
OCCT-97530-OT SESSION BY LICENSED OT 1 1.00 67.88 67.88
PHY-97110-PT SESSION BY LICENSED PT 6 7.25 492.13 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 14.50 984.26 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 13.20 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 42 1925.00 962.50 0.50
Subtotal (Total Children Is Unduplicated) 62 1964.25 4269.97 2.17
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Total 2013.75 7536.47 3.74
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Number of Children (Unduplicated) With at Least One Service 98
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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
133 2013.75 7536.47 0.00
Other 0 0.00 0.00 0.00
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Total 133 2013.75 7536.47 0.00