CMS/EIP Fiscal Report Center: 55
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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.50 562.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 8.00 444.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 76 145.00 10800.00 74.48
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 55 97.50 7312.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 22.50 1687.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 56 103.50 5744.25 55.50
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 9 9.00 436.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 20 20.00 970.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 16 16.00 776.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 28 29.00 1406.50 48.50
Subtotal (Total Children Is Unduplicated) 184 464.50 30494.75 65.65
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 41 432.50 21625.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 123 1226.75 83186.94 67.81
OCCT-97530HM-OT SESSION BY OT ASST 12 88.75 4820.90 54.32
PHY-97110-PT SESSION BY LICENSED PT 69 445.50 30240.54 67.88
PHY-97110HM-PT SESSION BY PT ASST 17 108.50 5893.72 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 183 1574.75 106877.06 67.87
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.00 26.40 13.20
Subtotal (Total Children Is Unduplicated) 261 3878.75 252670.56 65.14
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Total 4343.25 283165.31 65.20
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Number of Children (Unduplicated) With at Least One Service 323
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Center 55
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
5644 4343.25 283165.31 0.00
Other 0 0.00 0.00 0.00
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Total 5644 4343.25 283165.31 0.00