CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2011 ending 09/30/2011 Date of Report:11/30/2011 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 1.500000 55.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1 1.500000 55.5000 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.0800 21.0800
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 12.000000 900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 39.000000 2164.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 52 123.000000 9225.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 145.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.000000 194.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 14 14.000000 679.0000 48.5000
Subtotal (Total Children Is Unduplicated) 85 204.000000 13929.0800 68.2798
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 8.000000 200.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 292 1996.000000 99800.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 153.000000 10385.6400 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 1 3.000000 162.9600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 41 336.500000 22841.6200 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 34 239.500000 16257.2600 67.8800
Subtotal (Total Children Is Unduplicated) 329 2736.000000 149647.4800 54.6957
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Total 2941.500000 163632.0600 55.6288
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Number of Children (Unduplicated) With at Least One Service 360
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Center 53
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2889 2941.500000 163632.0600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2889 2941.500000 163632.0600 0.0000