CMS/EIP Fiscal Report Center: 05
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
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.500000 126.6000 50.6400
Subtotal (Total Children Is Unduplicated) 2 2.500000 126.6000 50.6400
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 2 5.000000 260.0200 52.0040
PHY-97110-PT SESSION BY LICENSED PT 4 16.000000 792.7000 49.5438
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 9.000000 473.2600 52.5844
Subtotal (Total Children Is Unduplicated) 7 30.000000 1525.9800 50.8660
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Total 32.500000 1652.5800 50.8486
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Number of Children (Unduplicated) With at Least One Service 9
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Center 05
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
41 32.500000 1652.5800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 41 32.500000 1652.5800 0.0000