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
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 5 10.50 675.00 64.29
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 43.30 3254.03 75.15
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 22.50 1687.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.75 206.06 74.93
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 7.50 445.50 59.40
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 11 10.44 506.40 48.51
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 0.66 32.00 48.48
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 2.66 129.00 48.50
Subtotal (Total Children Is Unduplicated) 49 102.31 7032.49 68.74
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 40 164.71 11182.89 67.89
OCCT-97530HM-OT SESSION BY OT ASST 3 8.50 461.72 54.32
PHY-97110-PT SESSION BY LICENSED PT 26 84.42 5729.80 67.87
PHY-97110HM-PT SESSION BY PT ASST 4 7.00 380.24 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 56 211.06 14332.16 67.91
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 51.00 45.70 0.90
Subtotal (Total Children Is Unduplicated) 100 526.69 32132.51 61.01
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Total 629.00 39165.00 62.27
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Number of Children (Unduplicated) With at Least One Service 130
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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
804 624.00 38844.98 0.00
Other 0 0.00 0.00 0.00
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Total 812 629.00 39165.00 320.02