CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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
EXIT-EXIT-TRANSITION ASSESSMENT 2 1.25 62.50 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 0.50 37.50 75.00
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) 7 6.00 362.50 60.42
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 3.00 1430.00 476.67
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 1.00 50.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 0.25 12.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 7 14.25 967.29 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 14 17.29 1173.87 67.89
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 38 1557.00 778.50 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 6 21.25 1062.50 50.00
Subtotal (Total Children Is Unduplicated) 61 1615.79 5586.67 3.46
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Total 1621.79 5949.17 3.67
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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 9.75 661.83 0.00
T 0 0.00 0.00 0.00
104 1612.04 5287.34 0.00
Other 0 0.00 0.00 0.00
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Total 107 1621.79 5949.17 0.00