CMS/EIP Fiscal Report Center: 10
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
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 9 9.00 436.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 7.00 339.50 48.50
Subtotal (Total Children Is Unduplicated) 17 19.00 921.50 48.50
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 10 34.00 850.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 117 1076.25 53812.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 102 388.75 26381.57 67.86
OCCT-97530HM-OT SESSION BY OT ASST 3 8.00 434.56 54.32
PHY-97110-PT SESSION BY LICENSED PT 201 664.75 45123.23 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 27.16 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 160 536.00 36383.68 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 5.50 298.76 54.32
Subtotal (Total Children Is Unduplicated) 396 2713.75 163311.46 60.18
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Total 2732.75 164232.96 60.10
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Number of Children (Unduplicated) With at Least One Service 401
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Center 10
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
1273 2732.75 164232.96 0.00
Other 0 0.00 0.00 0.00
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Total 1273 2732.75 164232.96 0.00