CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 3 4.50 258.00 57.33
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EI Services,Class #03
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.25 12.50 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 14.00 950.32 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 11 965.00 482.50 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 9 31.00 1550.00 50.00
Subtotal (Total Children Is Unduplicated) 24 1010.25 2995.32 2.96
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Total 1014.75 3253.32 3.21
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Number of Children (Unduplicated) With at Least One Service 27
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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
49 1014.75 3253.32 0.00
Other 0 0.00 0.00 0.00
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Total 49 1014.75 3253.32 0.00