CMS/EIP Fiscal Report Center: 53
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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 14.000000 1050.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 12.000000 666.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 48 108.000000 8100.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 145.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.000000 194.0000 48.5000
Subtotal (Total Children Is Unduplicated) 65 146.500000 10512.2500 71.7560
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 11.000000 275.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 290 2001.500000 100075.0000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 7.000000 350.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 26 210.750000 14305.7100 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 1 13.000000 706.1600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 33 257.000000 17445.1600 67.8800
PHY-97110HM-PT SESSION BY PT ASST 2 11.000000 597.5200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 41 230.000000 15612.4000 67.8800
Subtotal (Total Children Is Unduplicated) 326 2741.250000 149366.9500 54.4886
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Total 2887.750000 159879.2000 55.3646
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Number of Children (Unduplicated) With at Least One Service 356
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Center 53
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
2852 2887.750000 159879.2000 200.0000
Other 0 0.000000 0.0000 0.0000
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Total 2852 2887.750000 159879.2000 200.0000