CMS/EIP Fiscal Report Center: 51
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EIP DEI DEIP
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
EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 6.00 407.28 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 81.00 40.50 0.50
Subtotal (Total Children Is Unduplicated) 1 87.00 447.78 5.15
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Total 87.00 447.78 5.15
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Number of Children (Unduplicated) With at Least One Service 1
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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 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
12 87.00 447.78 0.00
Other 0 0.00 0.00 0.00
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Total 12 87.00 447.78 0.00