CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EXT
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 1.50 55.50 37.00
Subtotal (Total Children Is Unduplicated) 1 1.50 55.50 37.00
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 6 16.00 1048.50 65.53
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.50 262.50 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 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 80 137.91 10350.00 75.05
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 33 54.00 4050.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 21.00 1575.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 34 63.00 3525.75 55.96
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.00 242.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 22 22.00 1067.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.00 436.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 34 34.00 1649.00 48.50
Subtotal (Total Children Is Unduplicated) 157 372.91 24624.25 66.03
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.00 440.89 220.45
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 0.50 25.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.00 50.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.00 25.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 38.75 1937.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 51 270.50 13525.00 50.00
INTR-INTR-INTERPRETER 1 10.00 464.00 46.40
OCCT-97530-OT SESSION BY LICENSED OT 123 623.75 42340.15 67.88
OCCT-97530HM-OT SESSION BY OT ASST 14 67.75 3680.18 54.32
PHY-97110-PT SESSION BY LICENSED PT 84 474.75 32226.03 67.88
PHY-97110HM-PT SESSION BY PT ASST 15 41.75 2267.86 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 257 2865.67 99125.71 34.59
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 259 55371.0 42738.34 0.77
Subtotal (Total Children Is Unduplicated) 347 59768.4 238845.66 4.00
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Total 60142.83 263525.41 4.38
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Number of Children (Unduplicated) With at Least One Service 403
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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 4874 58359.33 149946.91 149946.91
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
2261 1783.50 113578.50 0.00
Other 0 0.00 0.00 0.00
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Total 7135 60142.83 263525.41 149946.91