CMS/EIP Fiscal Report Center: 55
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 0.833300 62.5000 75.0030
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 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 9 12.633300 947.5000 75.0002
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 48.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.000000 242.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 17 26.966600 1807.7500 67.0366
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 21 95.571385 6487.4000 67.8802
OCCT-97530HM-OT SESSION BY OT ASST 2 10.000000 543.2000 54.3200
PHY-97110-PT SESSION BY LICENSED PT 9 29.978597 2034.9700 67.8808
PHY-97110HM-PT SESSION BY PT ASST 3 3.211200 174.4400 54.3224
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 47 280.903519 19067.7300 67.8800
Subtotal (Total Children Is Unduplicated) 67 419.664701 28307.7400 67.4532
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Total 446.631301 30115.4900 67.4281
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Number of Children (Unduplicated) With at Least One Service 76
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Center 55
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 11 9.000000 583.8000 583.8000
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
562 437.631301 29531.6900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 573 446.631301 30115.4900 583.8000