CMS/EIP Fiscal Report Center: 54
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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 12.500000 937.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 23.500000 1304.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 2.000000 97.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 145.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 97.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 6.000000 291.0000 48.5000
Subtotal (Total Children Is Unduplicated) 36 63.000000 3785.7500 60.0913
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 204 729.250000 36462.5000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 1.000000 50.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 15 46.164200 3133.6300 67.8801
OCCT-97530HM-OT SESSION BY OT ASST 1 1.500000 81.4800 54.3200
PHY-97110-PT SESSION BY LICENSED PT 29 112.885600 7662.6800 67.8800
PHY-97110HM-PT SESSION BY PT ASST 2 6.000000 325.9200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 28 102.750000 6974.6700 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.000000 54.3200 54.3200
Subtotal (Total Children Is Unduplicated) 260 1000.549800 54745.2000 54.7151
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Total 1063.549800 58530.9500 55.0336
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Number of Children (Unduplicated) With at Least One Service 281
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Center 54
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
1059 1063.549800 58530.9500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1059 1063.549800 58530.9500 0.0000