CMS/EIP Fiscal Report Center: 51
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
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 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 6 6.00 291.00 48.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.00 150.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 7 22.50 1527.30 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 10.75 729.71 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 5.00 339.40 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 157.00 78.50 0.50
Subtotal (Total Children Is Unduplicated) 7 199.25 2879.23 14.45
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Total 205.25 3170.23 15.45
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Number of Children (Unduplicated) With at Least One Service 8
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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 3 117.00 274.38 274.38
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
27 88.25 2895.85 0.00
Other 0 0.00 0.00 0.00
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Total 30 205.25 3170.23 274.38