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: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
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 21.000000 1575.0000 75.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 12 23.500000 1706.7500 72.6277
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 5.000000 125.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 188 566.000000 28300.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 15.000000 1018.2000 67.8800
PHY-97110-PT SESSION BY LICENSED PT 21 59.000000 4004.9200 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 11 21.000000 1425.4800 67.8800
Subtotal (Total Children Is Unduplicated) 211 666.000000 34873.6000 52.3628
-----------------------------------------------------------------------------------------------------------------------
Total 689.500000 36580.3500 53.0534
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 221
-----------------------------------------------------------------------------------------------------------------------
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 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
683 689.500000 36580.3500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 683 689.500000 36580.3500 0.0000