CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Program Patients
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 8 7.63 370.23 48.52
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 39 39.00 1891.50 48.50
Subtotal (Total Children Is Unduplicated) 50 50.63 2455.73 48.50
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 41 142.48 9675.30 67.91
PHY-97110-PT SESSION BY LICENSED PT 47 167.50 11369.90 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 119 401.50 27171.80 67.68
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.00 26.40 13.20
Subtotal (Total Children Is Unduplicated) 165 713.48 48243.40 67.62
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Total 764.11 50699.13 66.35
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Number of Children (Unduplicated) With at Least One Service 184
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Center 57
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 4 7.00 455.78 455.78
463 757.11 50243.35 48941.37
Other 0 0.00 0.00 0.00
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Total 467 764.11 50699.13 49397.15