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
Agency Filter:EXT
Payclass Filters:MED
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
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 8.2800 8.2800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.0800 21.0800
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 18.500000 1387.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.000000 242.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.000000 194.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.000000 242.5000 48.5000
Subtotal (Total Children Is Unduplicated) 25 38.000000 2358.3600 62.0621
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 31 158.000000 7900.0000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 9 69.000000 3450.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 19 124.250000 8434.0900 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 2 3.000000 162.9600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 39 312.500000 21008.8600 67.2284
PHY-97110HM-PT SESSION BY PT ASST 1 1.500000 81.4800 54.3200
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 4 19.000000 950.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 69 343.393040 23309.5197 67.8800
Subtotal (Total Children Is Unduplicated) 131 1030.643040 65296.9097 63.3555
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Total 1068.643040 67655.2697 63.3095
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Number of Children (Unduplicated) With at Least One Service 138
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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 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
421 1068.643040 67655.2697 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 421 1068.643040 67655.2697 0.0000