CMS/EIP Fiscal Report Center: 10
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 5 6.000000 291.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 36.0000 36.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.000000 117.0000 39.0000
Subtotal (Total Children Is Unduplicated) 9 10.000000 444.0000 44.4000
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 8.000000 915.8200 114.4775
OCCT-97530-OT SESSION BY LICENSED OT 72 317.750000 21410.4700 67.3815
OCCT-97530HM-OT SESSION BY OT ASST 6 12.500000 578.7200 46.2976
PHY-97110-PT SESSION BY LICENSED PT 115 397.500000 26412.5400 66.4466
PHY-97110HM-PT SESSION BY PT ASST 1 3.500000 190.1200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 106 388.750000 26297.4300 67.6461
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 11.500000 624.6800 54.3200
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 20.000000 10.0000 0.5000
Subtotal (Total Children Is Unduplicated) 196 1159.500000 76439.7800 65.9248
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Total 1169.500000 76883.7800 65.7407
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Number of Children (Unduplicated) With at Least One Service 200
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Center 10
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 1 20.000000 10.0000 10.0000
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
574 1149.500000 76873.7800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 575 1169.500000 76883.7800 10.0000