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: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
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
Subtotal (Total Children Is Unduplicated) 2 4.000000 300.0000 75.0000
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 8.111000 405.5500 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 2.000000 135.7600 67.8800
PHY-97110-PT SESSION BY LICENSED PT 2 4.000000 271.5200 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 4.811200 326.5843 67.8800
Subtotal (Total Children Is Unduplicated) 8 18.922200 1139.4143 60.2157
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Total 22.922200 1439.4143 62.7956
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Number of Children (Unduplicated) With at Least One Service 10
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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 1 1.000000 50.0000 50.0000
T 0 0.000000 0.0000 0.0000
23 21.922200 1389.4143 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 24 22.922200 1439.4143 50.0000