CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 4 4.00 194.00 48.50
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 41.00 2050.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 16 51.50 3495.82 67.88
PHY-97110-PT SESSION BY LICENSED PT 11 28.98 1969.90 67.97
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 21.00 1425.48 67.88
Subtotal (Total Children Is Unduplicated) 34 142.48 8941.20 62.75
----------------------------------------------------------------------------------------------------------------
Total 146.48 9135.20 62.36
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 35
----------------------------------------------------------------------------------------------------------------
Center 04
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 11 42.00 2098.50 2098.50
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 47 104.48 7036.70 7036.74
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 58 146.48 9135.20 9135.24