CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 48.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 145.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.000000 339.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 32 31.618600 1533.5000 48.4999
Subtotal (Total Children Is Unduplicated) 41 42.618600 2067.0000 48.5000
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 46.000000 2300.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 28 111.000000 7534.6800 67.8800
PHY-97110-PT SESSION BY LICENSED PT 44 184.000000 12489.9200 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 63 277.828700 18859.0100 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 12.368200 671.8400 54.3199
Subtotal (Total Children Is Unduplicated) 112 631.196900 41855.4500 66.3112
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Total 673.815500 43922.4500 65.1847
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Number of Children (Unduplicated) With at Least One Service 132
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Center 57
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 8 13.315500 867.4900 867.4900
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 14 49.500000 2607.6000 2607.6000
315 611.000000 40447.3600 40447.3600
Other 0 0.000000 0.0000 0.0000
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Total 337 673.815500 43922.4500 43922.4500