CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 7.00 339.50 48.50
Subtotal (Total Children Is Unduplicated) 15 17.00 824.50 48.50
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 40.00 2000.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 45 135.50 9197.74 67.88
PHY-97110-PT SESSION BY LICENSED PT 21 65.00 4412.20 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 153.25 10402.61 67.88
Subtotal (Total Children Is Unduplicated) 85 393.75 26012.55 66.06
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Total 410.75 26837.05 65.34
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Number of Children (Unduplicated) With at Least One Service 90
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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 12 46.00 2495.18 2495.18
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 182 364.75 24341.87 24341.87
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 194 410.75 26837.05 26837.05