CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 Page: 1
List order: No List
Payclass Filters:LEA
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 4 4.000000 194.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.000000 97.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 8 9.000000 436.5000 48.5000
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EI Services,Class #03
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 4 632.000000 15800.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 82 2846.000000 71150.0000 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 5.000000 250.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 11 160.000000 8000.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 104.250000 7076.4900 67.8800
PHY-97110-PT SESSION BY LICENSED PT 43 188.500000 12795.3800 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 42 179.250000 12167.4900 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.2000 13.2000
Subtotal (Total Children Is Unduplicated) 97 4116.000000 127252.5600 30.9166
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Total 4125.000000 127689.0600 30.9549
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Number of Children (Unduplicated) With at Least One Service 97
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Center 04
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
547 4125.000000 127689.0600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 547 4125.000000 127689.0600 0.0000