CMS/EIP Fiscal Report Center: 07
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Program Patients
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
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 4 4.00 194.00 48.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.00 50.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 3 13.50 916.38 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 4.00 271.52 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 14 45.75 3105.51 67.88
Subtotal (Total Children Is Unduplicated) 16 64.25 4343.41 67.60
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Total 68.25 4537.41 66.48
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Number of Children (Unduplicated) With at Least One Service 17
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Center 07
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
27 68.25 4537.41 0.00
Other 0 0.00 0.00 0.00
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Total 27 68.25 4537.41 0.00