CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2008 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-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 2 2.00 123.50 61.75
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EI Services,Class #03
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 13 36.75 1837.50 50.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 8 97.00 2425.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 24 228.00 11400.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 100.00 5000.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 5 15.50 1052.14 67.88
PHY-97110-PT SESSION BY LICENSED PT 44 316.50 21484.02 67.88
PHY-97110HM-PT SESSION BY PT ASST 4 31.00 1683.92 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 18 43.75 2969.75 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 50 8070.00 3369.95 0.42
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 10 138.00 6900.00 50.00
Subtotal (Total Children Is Unduplicated) 150 9076.50 58122.28 6.40
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Total 9078.50 58245.78 6.42
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Number of Children (Unduplicated) With at Least One Service 151
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Center 01
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 26 2434.00 1217.00 1217.00
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 14 58.00 2175.00 2175.00
382 6582.50 54653.78 2162.97
Other 2 4.00 200.00 0.00
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Total 424 9078.50 58245.78 5554.97