CMS/EIP Fiscal Report              Center: 04 
Services beginning 10/01/2011 ending 12/31/2011                Date of Report:02/16/2012   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
  OCTH-97003-OT EVAL BY LICENSED OT, INITIAL               1               1.000000           48.5000           48.5000
  PSTH-97001-EVAL BY LICENSED PT, INITIAL                  1               1.000000           48.5000           48.5000
  SPCH-92506-SPEECH EVAL BY LICENSED SLP                   3               3.000000          145.5000           48.5000
Subtotal (Total Children Is Unduplicated)                  5               5.000000          242.5000           48.5000
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EI Services,Class #03
  EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF           13              77.000000         3850.0000           50.0000
  OCCT-97530-OT SESSION BY LICENSED OT                     5              20.000000         1357.6000           67.8800
  PHY-97110-PT SESSION BY LICENSED PT                      6              22.500000         1527.3000           67.8800
  SPL-92507-SPL THERAPY SESSION BY LICENSED SLP           10              37.500000         2545.5000           67.8800
Subtotal (Total Children Is Unduplicated)                 32             157.000000         9280.4000           59.1108
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Total                                                                    162.000000         9522.9000           58.7833
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Number of Children (Unduplicated) With at Least One Service         33
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Center 04
Flag      Claims          Units         Chgs         Paid
---------------------------------------------------------
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             22      77.000000    3850.0000    3650.0000 
D              0       0.000000       0.0000       0.0000 
S              0       0.000000       0.0000       0.0000 
H              1       3.000000     203.6400     203.6400 
T              0       0.000000       0.0000       0.0000 
               0       0.000000       0.0000       0.0000 
Other         39      82.000000    5469.2600    5420.7600 
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Total         62     162.000000    9522.9000    9274.4000