CMS/EIP Fiscal Report Center: 51
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
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 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 2 2.00 97.00 48.50
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EI Services,Class #03
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 10 24.00 1200.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 11 49.75 3377.03 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 3.00 203.64 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 18 1178.00 589.00 0.50
Subtotal (Total Children Is Unduplicated) 39 1254.75 5369.67 4.28
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Total 1256.75 5466.67 4.35
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Number of Children (Unduplicated) With at Least One Service 39
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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 23 1182.00 841.14 841.14
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
47 74.75 4625.53 0.00
Other 0 0.00 0.00 0.00
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Total 70 1256.75 5466.67 841.14