CMS/EIP Fiscal Report Center: 57
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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
EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.50 25.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 0.50 25.00 50.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 7 848.00 7632.00 9.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 8.00 400.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 2.00 135.76 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 10.50 712.74 67.88
TRAN-TRAN-FAMILY TRANSPORTATION 28 1200.00 120000.00 100.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 10 546.00 273.00 0.50
Subtotal (Total Children Is Unduplicated) 46 2615.50 129203.50 49.40
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Total 2615.50 129203.50 49.40
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Number of Children (Unduplicated) With at Least One Service 46
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Center 57
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 1 60.00 30.00 30.00
69 2186.00 127835.76 0.00
Other 12 369.50 1337.74 1337.74
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Total 82 2615.50 129203.50 1367.74