CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2012 ending 06/30/2012 Date of Report:08/16/2012 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 2 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 15.000000 832.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 44 84.000000 6300.0000 75.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 97.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.000000 97.0000 48.5000
Subtotal (Total Children Is Unduplicated) 59 122.500000 8672.0000 70.7918
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 4 10.000000 696.5400 69.6540
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 4.000000 100.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 281 1837.750000 91887.5000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 2.000000 100.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 14 108.000000 7331.0400 67.8800
PHY-97110-PT SESSION BY LICENSED PT 27 210.750000 14305.7100 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 14 83.500000 5667.9800 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.000000 26.4000 13.2000
Subtotal (Total Children Is Unduplicated) 309 2258.000000 120115.1700 53.1954
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Total 2380.500000 128787.1700 54.1009
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Number of Children (Unduplicated) With at Least One Service 340
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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
2361 2380.500000 128787.1700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2361 2380.500000 128787.1700 0.0000