CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 0.50 25.00 50.00
Subtotal (Total Children Is Unduplicated) 3 2.50 122.00 48.80
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 6.00 300.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.25 12.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 2.50 125.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 0.50 25.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.00 30.00 30.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 1.25 62.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 2 2.00 135.76 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 0.50 33.94 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 11 15.76 1069.62 67.87
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 41 1555.00 777.50 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 11 27.75 1387.50 50.00
Subtotal (Total Children Is Unduplicated) 64 1612.51 3959.32 2.46
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Total 1615.01 4081.32 2.53
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Number of Children (Unduplicated) With at Least One Service 66
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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
106 1615.01 4081.32 0.00
Other 0 0.00 0.00 0.00
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Total 106 1615.01 4081.32 0.00