CMS/EIP Fiscal Report Center: 09
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 Page: 1
Agency Filter:EXT
Payclass Filters:OTHER
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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
Subtotal (Total Children Is Unduplicated) 1 2.00 150.00 75.00
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 6.00 407.28 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 8.50 576.98 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 5.50 373.34 67.88
Subtotal (Total Children Is Unduplicated) 3 20.00 1357.60 67.88
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Total 22.00 1507.60 68.53
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Number of Children (Unduplicated) With at Least One Service 4
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Center 09
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
8 22.00 1507.60 0.00
Other 0 0.00 0.00 0.00
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Total 8 22.00 1507.60 0.00