CMS/EIP Fiscal Report Center: 51
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 3 3.00 145.50 48.50
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EI Services,Class #03
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 8 20.50 1025.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 8 32.00 2172.16 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 4.00 217.28 54.32
Subtotal (Total Children Is Unduplicated) 16 56.50 3414.44 60.43
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Total 59.50 3559.94 59.83
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Number of Children (Unduplicated) With at Least One Service 16
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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
34 59.50 3559.94 0.00
Other 0 0.00 0.00 0.00
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Total 34 59.50 3559.94 0.00