CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 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
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 9 9.00 436.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 14.00 679.00 48.50
Subtotal (Total Children Is Unduplicated) 24 28.00 1358.00 48.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 6.00 300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 42 137.50 9333.50 67.88
OCCT-97530HM-OT SESSION BY OT ASST 4 7.50 407.40 54.32
PHY-97110-PT SESSION BY LICENSED PT 18 44.00 2986.72 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 4.50 244.44 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 54 162.25 10936.71 67.41
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.50 6.60 13.20
Subtotal (Total Children Is Unduplicated) 90 362.25 24215.37 66.85
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Total 390.25 25573.37 65.53
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Number of Children (Unduplicated) With at Least One Service 95
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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 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 198 390.25 25573.37 25593.73
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 198 390.25 25573.37 25593.73