CMS/EIP Fiscal Report Center: 51
Services beginning 10/01/2008 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 3.00 203.64 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 37.00 18.50 0.50
Subtotal (Total Children Is Unduplicated) 1 40.00 222.14 5.55
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Total 40.00 222.14 5.55
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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
6 40.00 222.14 0.00
Other 0 0.00 0.00 0.00
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Total 6 40.00 222.14 0.00