CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:GR
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-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.000000 97.0000 48.5000
Subtotal (Total Children Is Unduplicated) 6 13.000000 853.7500 65.6731
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 312.0000 312.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 21 25.250000 1262.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 4 1.500000 37.5000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 62 53.500000 2675.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 4 1.250000 31.2500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 9 11.000000 806.5200 73.3200
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 47 155.889000 7794.4500 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 8.000000 543.0400 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 1 8.000000 434.5600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 67.8800 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 12.188700 827.3690 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 290 34847.00000 17423.5000 0.5000
Subtotal (Total Children Is Unduplicated) 301 35125.57770 32215.5690 0.9172
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Total 35138.577700 33069.3190 0.9411
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Number of Children (Unduplicated) With at Least One Service 301
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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 622 32232.250000 29173.7800 29173.7800
T 0 0.000000 0.0000 0.0000
88 2906.327700 3895.5390 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 710 35138.577700 33069.3190 29173.7800