CMS/EIP Fiscal Report Center: 51
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 8 8.00 388.00 48.50
Subtotal (Total Children Is Unduplicated) 9 9.00 436.50 48.50
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 8.00 3230.45 403.81
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 8.00 400.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 11 85.50 5752.89 67.29
OCCT-97530HM-OT SESSION BY OT ASST 1 1.50 81.48 54.32
PHY-97110-PT SESSION BY LICENSED PT 2 28.75 1951.55 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 19.50 1323.66 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 401.00 200.50 0.50
Subtotal (Total Children Is Unduplicated) 13 553.25 12994.85 23.49
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Total 562.25 13431.35 23.89
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Number of Children (Unduplicated) With at Least One Service 13
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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 5 205.00 417.38 417.38
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
77 357.25 13013.97 0.00
Other 0 0.00 0.00 0.00
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Total 82 562.25 13431.35 417.38