CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 76.50 38.25
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.00 242.50 48.50
Subtotal (Total Children Is Unduplicated) 11 11.00 513.00 46.64
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 23 79.50 5396.46 67.88
PHY-97110-PT SESSION BY LICENSED PT 32 166.00 11129.30 67.04
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 32 104.75 6948.75 66.34
SPL-92508-GROUP SPL SESSION PER CHILD 4 12.00 158.40 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 150.00 75.00 0.50
Subtotal (Total Children Is Unduplicated) 66 512.25 23707.91 46.28
----------------------------------------------------------------------------------------------------------------
Total 523.25 24220.91 46.29
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 68
----------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
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 1 150.00 75.00 75.00
H 0 0.00 0.00 0.00
T 1 1.50 101.82 101.82
168 371.75 24044.09 18504.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 170 523.25 24220.91 18680.82