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: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 1 2.000000 150.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 145.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 97.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 11 11.000000 533.5000 48.5000
Subtotal (Total Children Is Unduplicated) 15 18.000000 926.0000 51.4444
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EI Services,Class #03
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 7.000000 382.1800 54.5971
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 8.000000 400.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 71.833830 4855.7404 67.5968
OCCT-97530HM-OT SESSION BY OT ASST 1 5.250000 285.1800 54.3200
PHY-97110-PT SESSION BY LICENSED PT 31 222.990000 15137.4200 67.8839
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 9.000000 450.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 51 217.409410 14845.5504 68.2838
SPL-92508-GROUP SPL SESSION PER CHILD 1 25.000000 330.0000 13.2000
Subtotal (Total Children Is Unduplicated) 79 568.483240 36786.0708 64.7092
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Total 586.483240 37712.0708 64.3020
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Number of Children (Unduplicated) With at Least One Service 82
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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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
236 583.483240 37508.4308 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 237 586.483240 37712.0708 203.6400