CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Agency Filter:EXT
Payclass Filters:MED
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 4 7.00 525.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 7.00 388.50 55.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 9 19.00 1156.00 60.84
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 119 731.00 36550.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 32 210.50 14288.74 67.88
OCCT-97530HM-OT SESSION BY OT ASST 4 9.50 516.04 54.32
PHY-97110-PT SESSION BY LICENSED PT 65 324.50 21964.68 67.69
PHY-97110HM-PT SESSION BY PT ASST 3 11.50 624.68 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 132 786.75 53404.59 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 4 6.00 79.20 13.20
Subtotal (Total Children Is Unduplicated) 275 2079.75 127427.93 61.27
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Total 2098.75 128583.93 61.27
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Number of Children (Unduplicated) With at Least One Service 276
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Center 06
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
2476 2098.75 128583.93 0.00
Other 0 0.00 0.00 0.00
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Total 2476 2098.75 128583.93 0.00