CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2011 ending 09/30/2011 Date of Report:12/01/2011 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
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 1 2.000000 150.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 97.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.000000 291.0000 48.5000
Subtotal (Total Children Is Unduplicated) 10 11.000000 586.5000 53.3182
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.000000 483.0600 241.5300
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 30.000000 1500.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 114.000000 7738.3200 67.8800
PHY-97110-PT SESSION BY LICENSED PT 20 129.063640 8760.8400 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 82.337650 5589.0797 67.8800
Subtotal (Total Children Is Unduplicated) 41 357.401290 24071.2997 67.3509
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Total 368.401290 24657.7997 66.9319
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Number of Children (Unduplicated) With at Least One Service 46
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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 17 17.000000 991.5400 991.5400
T 20 20.000000 1178.8000 1178.8000
337 331.401290 22487.4597 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 374 368.401290 24657.7997 2170.3400