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: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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 3 3.500000 206.7500 59.0714
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 20.000000 1000.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 5.800000 290.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 42.000000 2837.4000 67.5571
PHY-97110-PT SESSION BY LICENSED PT 9 24.449000 1659.6400 67.8817
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 33.500000 2273.9800 67.8800
Subtotal (Total Children Is Unduplicated) 26 126.749000 8111.0200 63.9928
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Total 130.249000 8317.7700 63.8605
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Number of Children (Unduplicated) With at Least One Service 27
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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
119 130.249000 8317.7700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 119 130.249000 8317.7700 0.0000