CMS/EIP Fiscal Report Center: 51
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
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
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 2 2.00 97.00 48.50
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EI Services,Class #03
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 10 70.00 3500.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 5 19.00 1289.72 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.50 101.82 67.88
Subtotal (Total Children Is Unduplicated) 16 90.50 4891.54 54.05
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Total 92.50 4988.54 53.93
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Number of Children (Unduplicated) With at Least One Service 17
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Center 51
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
43 92.50 4988.54 0.00
Other 0 0.00 0.00 0.00
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Total 43 92.50 4988.54 0.00