CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 0.25 12.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 1.50 101.82 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 4.00 271.52 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 7 210.00 105.00 0.50
Subtotal (Total Children Is Unduplicated) 10 216.75 540.84 2.50
----------------------------------------------------------------------------------------------------------------
Total 216.75 540.84 2.50
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 10
----------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
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 3 5.50 373.34 0.00
T 0 0.00 0.00 0.00
9 211.25 167.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 12 216.75 540.84 0.00