CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EXT
Payclass Filters:TPIN
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
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 1 1.00 48.50 48.50
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.00 30.00 30.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 4.50 225.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 25.00 1250.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 54 193.00 13100.84 67.88
OCCT-97530HM-OT SESSION BY OT ASST 6 5.00 271.60 54.32
PHY-97110-PT SESSION BY LICENSED PT 80 329.00 22332.52 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 33.94 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 148 600.75 40778.91 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 72.00 36.00 0.50
Subtotal (Total Children Is Unduplicated) 243 1230.75 78058.81 63.42
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Total 1231.75 78107.31 63.41
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Number of Children (Unduplicated) With at Least One Service 243
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Center 06
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
1719 1231.75 78107.31 0.00
Other 0 0.00 0.00 0.00
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Total 1719 1231.75 78107.31 0.00