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
Payclass Filters:LEA
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 1 2.000000 97.0000 48.5000
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EI Services,Class #03
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 40 3872.000000 96800.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 98 2736.000000 68400.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 11 167.000000 8350.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 57 200.500000 13609.9400 67.8800
PHY-97110-PT SESSION BY LICENSED PT 55 203.250000 13796.6100 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 53 151.000000 10249.8800 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 15 17.500000 231.0000 13.2000
Subtotal (Total Children Is Unduplicated) 147 7347.250000 211437.4300 28.7778
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Total 7349.250000 211534.4300 28.7831
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Number of Children (Unduplicated) With at Least One Service 147
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Center 04
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
774 7349.250000 211534.4300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 774 7349.250000 211534.4300 0.0000