CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Agency Filter:EXT
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
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 2.50 125.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 6 7.25 492.13 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 9 9.50 644.86 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 35 1146.00 648.00 0.57
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 9 36.25 1812.50 50.00
Subtotal (Total Children Is Unduplicated) 57 1206.75 4036.32 3.34
----------------------------------------------------------------------------------------------------------------
Total 1213.75 4278.82 3.53
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 60
----------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
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 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
92 1213.75 4278.82 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 92 1213.75 4278.82 0.00