CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
Subtotal (Total Children Is Unduplicated) 2 3.50 262.50 75.00
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 4 19.00 1289.72 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 12.50 848.50 67.88
Subtotal (Total Children Is Unduplicated) 4 31.50 2138.22 67.88
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Total 35.00 2400.72 68.59
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Number of Children (Unduplicated) With at Least One Service 6
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Center 09
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
14 35.00 2400.72 0.00
Other 0 0.00 0.00 0.00
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Total 14 35.00 2400.72 0.00