CMS/EIP Fiscal Report Center: 51
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Agency Filter:EXT
Payclass Filters:GR
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
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 4 4.00 500.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 4 4.00 200.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 75.00 50.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 75.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 31 32.50 2336.50 71.89
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.50 123.50 49.40
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.50 225.00 50.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 7.00 375.00 53.57
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 46 49.00 3450.00 70.41
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 15.00 727.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.00 291.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 19 19.00 921.50 48.50
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 2.00 140.00 70.00
Subtotal (Total Children Is Unduplicated) 92 150.50 9590.00 63.72
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 14.00 4321.17 308.66
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 2.00 137.72 68.86
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 17 19.25 869.50 45.17
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 3.00 150.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 8 5.75 287.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.50 25.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 6 2.00 50.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 10 7.75 387.50 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 9 180.50 9012.50 49.93
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 79 491.50 24575.00 50.00
INTR-INTR-INTERPRETER 9 25.75 644.50 25.03
OCCT-97530-OT SESSION BY LICENSED OT 41 248.25 16111.79 64.90
OCCT-97530HM-OT SESSION BY OT ASST 1 1.00 54.32 54.32
PHY-97110-PT SESSION BY LICENSED PT 28 157.00 9073.72 57.79
PHY-97110HM-PT SESSION BY PT ASST 2 6.00 325.92 54.32
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 95 638.50 41996.54 65.77
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 442 100347 47902.10 0.48
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 3 7.50 445.00 59.33
Subtotal (Total Children Is Unduplicated) 466 102159 156407.22 1.53
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Total 102309.75 165997.22 1.62
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Number of Children (Unduplicated) With at Least One Service 475
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Center 51
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 2160 102298.00 165280.32 165280.32
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
11 11.75 716.90 0.00
Other 0 0.00 0.00 0.00
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Total 2171 102309.75 165997.22 165280.32