CMS/EIP Fiscal Report Center: 51
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:OTHER
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 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 2 2.00 97.00 48.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 5.00 250.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 10 57.75 3869.22 67.00
PHY-97110-PT SESSION BY LICENSED PT 2 3.50 237.58 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.00 203.64 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 244.00 122.00 0.50
Subtotal (Total Children Is Unduplicated) 10 313.25 4682.44 14.95
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Total 315.25 4779.44 15.16
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Number of Children (Unduplicated) With at Least One Service 10
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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 2 88.00 143.00 143.00
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
34 227.25 4636.44 0.00
Other 0 0.00 0.00 0.00
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Total 36 315.25 4779.44 143.00