CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EXT
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
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
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 5 5.00 242.50 48.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 14.00 700.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 12 40.78 2737.68 67.13
PHY-97110-PT SESSION BY LICENSED PT 4 22.00 1493.36 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 17.50 1187.90 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.50 19.80 13.20
Subtotal (Total Children Is Unduplicated) 24 95.78 6138.74 64.09
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Total 100.78 6381.24 63.32
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Number of Children (Unduplicated) With at Least One Service 27
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Center 04
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 4 17.00 939.40 939.40
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 41 83.78 5441.84 5525.36
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 45 100.78 6381.24 6464.76