CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 12.000000 666.0000 55.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.000000 194.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 97.0000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.000000 150.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 12 12.000000 582.0000 48.5000
Subtotal (Total Children Is Unduplicated) 33 69.000000 4194.0000 60.7826
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 7.000000 175.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 37.750000 1919.6800 50.8525
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 8.000000 400.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 19 83.333830 5636.3604 67.6359
OCCT-97530HM-OT SESSION BY OT ASST 1 5.250000 285.1800 54.3200
PHY-97110-PT SESSION BY LICENSED PT 37 243.990000 16562.9000 67.8835
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 9.000000 450.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 56 233.409410 15931.6304 68.2562
SPL-92508-GROUP SPL SESSION PER CHILD 1 25.000000 330.0000 13.2000
Subtotal (Total Children Is Unduplicated) 97 654.733240 41790.7508 63.8287
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Total 723.733240 45984.7508 63.5383
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Number of Children (Unduplicated) With at Least One Service 107
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Center 52
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 3.000000 203.6400 203.6400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 36 67.750000 4397.6900 0.0000
T 0 0.000000 0.0000 0.0000
274 652.983240 41383.4208 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 311 723.733240 45984.7508 203.6400