CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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
VISD-VISD-VISION EVALUATION DIAGNOSTIC 1 1.00 100.00 100.00
VISF-VISF-VISION EVALUATION FUNCTIONAL 3 3.25 162.50 50.00
Subtotal (Total Children Is Unduplicated) 4 4.25 262.50 61.76
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.50 25.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 0.25 12.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 3 4.00 271.52 67.88
PHY-97110-PT SESSION BY LICENSED PT 3 1.25 84.85 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 27.16 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 16.04 1089.02 67.89
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 34 1498.00 749.00 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 6 21.25 1062.50 50.00
Subtotal (Total Children Is Unduplicated) 53 1541.79 3321.55 2.15
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Total 1546.04 3584.05 2.32
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Number of Children (Unduplicated) With at Least One Service 57
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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 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
91 1546.04 3584.05 0.00
Other 0 0.00 0.00 0.00
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Total 91 1546.04 3584.05 0.00