CMS/EIP Fiscal Report Center: 07
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:LEA
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
EVAL-EVAL-DEVELOPMENTAL EVALUATION 20 20.00 1000.00 50.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 14.00 679.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.00 388.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 20 20.00 970.00 48.50
Subtotal (Total Children Is Unduplicated) 22 62.00 3037.00 48.98
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EI Services,Class #03
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 1 1.00 50.00 50.00
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Total 63.00 3087.00 49.00
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Number of Children (Unduplicated) With at Least One Service 22
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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
63 63.00 3087.00 0.00
Other 0 0.00 0.00 0.00
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Total 63 63.00 3087.00 0.00