CMS/EIP Fiscal Report Center: 51
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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
EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 3.00 203.64 67.88
Subtotal (Total Children Is Unduplicated) 1 3.00 203.64 67.88
----------------------------------------------------------------------------------------------------------------
Total 3.00 203.64 67.88
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1
----------------------------------------------------------------------------------------------------------------
Center 51
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 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1 3.00 203.64 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1 3.00 203.64 0.00