CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Payclass Filters:OTHER
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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.50 48.50 32.33
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.50 48.50 32.33
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.00 145.50 36.38
Subtotal (Total Children Is Unduplicated) 3 7.00 242.50 34.64
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 5 3.50 175.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 2.25 112.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 7 8.75 593.95 67.88
PHY-97110-PT SESSION BY LICENSED PT 4 2.75 186.67 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 27.16 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 11 13.50 916.38 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 41 1356.00 753.00 0.56
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 9 36.25 1812.50 50.00
Subtotal (Total Children Is Unduplicated) 65 1423.50 4577.16 3.22
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Total 1430.50 4819.66 3.37
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Number of Children (Unduplicated) With at Least One Service 68
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Center 52
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 3 5.50 373.34 0.00
T 0 0.00 0.00 0.00
101 1425.00 4446.32 0.00
Other 0 0.00 0.00 0.00
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Total 104 1430.50 4819.66 0.00