CMS/EIP Fiscal Report Center: 51
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 6 6.00 291.00 48.50
----------------------------------------------------------------------------------------------------------------
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 1 2.00 135.76 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 113.00 56.50 0.50
Subtotal (Total Children Is Unduplicated) 7 152.25 2653.59 17.43
----------------------------------------------------------------------------------------------------------------
Total 158.25 2944.59 18.61
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 8
----------------------------------------------------------------------------------------------------------------
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
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
21 41.25 2670.21 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 24 158.25 2944.59 274.38