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:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 25.500000 1912.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 12.000000 900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 5.000000 242.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.000000 50.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.000000 145.5000 48.5000
Subtotal (Total Children Is Unduplicated) 30 60.500000 4137.5000 68.3884
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 559.9500 559.9500
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 2.000000 100.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 7.000000 175.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 195.000000 9165.0000 47.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 17 11.750000 587.5000 50.0000
INTR-INTR-INTERPRETER 3 13.000000 260.0000 20.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 20.250000 1374.5700 67.8800
PHY-97110-PT SESSION BY LICENSED PT 2 2.000000 135.7600 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 26.750000 1815.7900 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.2000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 45 10366.00000 5317.5000 0.5130
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 9 27.000000 1350.0000 50.0000
Subtotal (Total Children Is Unduplicated) 84 10673.75000 20904.2700 1.9585
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Total 10734.250000 25041.7700 2.3329
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Number of Children (Unduplicated) With at Least One Service 110
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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 50 91.000000 5986.7000 0.0000
T 0 0.000000 0.0000 0.0000
157 10641.000000 18920.2200 0.0000
Other 3 2.250000 134.8500 0.0000
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Total 210 10734.250000 25041.7700 0.0000