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: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
EVAL-EVAL-DEVELOPMENTAL EVALUATION 10 17.50 1025.00 58.57
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 2.00 111.00 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.22 316.87 75.09
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.23 167.80 75.25
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.06 4.98 83.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 77 115.06 8635.73 75.05
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 54 76.73 5756.70 75.03
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 11.87 889.78 74.96
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 11.50 667.50 58.04
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 13 11.08 540.18 48.75
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 25 25.60 1241.70 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 3.25 148.94 45.83
PSTH-97001-EVAL BY LICENSED PT, INITIAL 15 14.28 692.62 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 28 26.18 1270.10 48.51
Subtotal (Total Children Is Unduplicated) 166 321.56 21468.90 66.76
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.00 50.00 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 1.00 50.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 7.00 350.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 10.00 500.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 104 679.68 46122.39 67.86
OCCT-97530HM-OT SESSION BY OT ASST 6 12.47 678.26 54.39
PHY-97110-PT SESSION BY LICENSED PT 60 402.28 27283.82 67.82
PHY-97110HM-PT SESSION BY PT ASST 9 36.54 1988.50 54.42
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 132 829.28 56256.11 67.84
SPL-92508-GROUP SPL SESSION PER CHILD 2 0.89 60.19 67.63
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 51.00 45.70 0.90
Subtotal (Total Children Is Unduplicated) 206 2033.14 133422.41 65.62
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Total 2354.70 154891.31 65.78
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Number of Children (Unduplicated) With at Least One Service 277
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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 8 5.00 320.02 320.02
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
3641 2349.70 154571.29 0.00
Other 0 0.00 0.00 0.00
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Total 3649 2354.70 154891.31 320.02