CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 4 5.00 242.50 48.50
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EI Services,Class #03
CONOF-CONOF-CONSULT, OT, FACE TO FACE 6 10.00 500.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 8.50 425.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 6 15.00 750.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 17 34.25 2324.89 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 2.50 135.80 54.32
PHY-97110-PT SESSION BY LICENSED PT 12 23.75 1612.15 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 22 70.75 4802.51 67.88
Subtotal (Total Children Is Unduplicated) 35 164.75 10550.35 64.04
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Total 169.75 10792.85 63.58
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Number of Children (Unduplicated) With at Least One Service 35
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Center 06
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
291 169.75 10792.85 0.00
Other 0 0.00 0.00 0.00
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Total 291 169.75 10792.85 0.00