CMS/EIP Fiscal Report Center: 54
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:TPIN
Eligibility Filter:DEI Only
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 262.50 175.00
Subtotal (Total Children Is Unduplicated) 1 1.50 262.50 175.00
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 12.50 848.50 67.88
Subtotal (Total Children Is Unduplicated) 1 12.50 848.50 67.88
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Total 14.00 1111.00 79.36
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Number of Children (Unduplicated) With at Least One Service 2
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Center 54
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
4 14.00 1111.00 0.00
Other 0 0.00 0.00 0.00
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Total 4 14.00 1111.00 0.00