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: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 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 0.327800 24.5850 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 24.000000 1800.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 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) 22 40.327800 2709.5850 67.1890
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 48.000000 2400.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 37.000000 2511.5600 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 2 27.000000 1466.6400 54.3200
PHY-97110-PT SESSION BY LICENSED PT 17 110.000000 7466.8000 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 11 52.331525 3552.2645 67.8800
Subtotal (Total Children Is Unduplicated) 35 275.331525 17447.2645 63.3682
-----------------------------------------------------------------------------------------------------------------------
Total 315.659325 20156.8495 63.8563
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 53
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 21 21.000000 1155.7800 1155.7800
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 23 23.000000 1221.5200 1221.5200
269 271.659325 17779.5495 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 313 315.659325 20156.8495 2377.3000