CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:OTHER
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 3 3.00 150.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 5 4.50 112.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.00 100.00 50.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 9 1372.00 12348.00 9.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 3.00 150.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 3 8.50 576.98 67.88
PHY-97110-PT SESSION BY LICENSED PT 3 7.00 475.16 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 13 29.00 1968.52 67.88
TRAN-TRAN-FAMILY TRANSPORTATION 29 1020.00 93841.00 92.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 39 1768.00 3272.00 1.85
Subtotal (Total Children Is Unduplicated) 71 4217.00 112994.16 26.79
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Total 4217.00 112994.16 26.79
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Number of Children (Unduplicated) With at Least One Service 71
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Center 57
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
122 4064.50 110120.74 0.00
Other 37 152.50 2873.42 2873.42
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Total 159 4217.00 112994.16 2873.42