CMS/EIP Fiscal Report Center: 55
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-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 35 53.500000 4012.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 13.232000 992.4000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 10 10.000000 485.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 7.417500 359.7500 48.5002
Subtotal (Total Children Is Unduplicated) 57 98.649500 6829.9000 69.2340
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 1065.7500 532.8750
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 5 5.000000 250.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 17 22.750000 568.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 5 5.000000 250.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 11 19.500000 487.5000 25.0000
CONPP-CONPP-CONSULT, PT, PHONE 3 1.500000 37.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.250000 31.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 14 109.000000 5450.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 40 191.684586 13011.5500 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 5 15.000000 814.8000 54.3200
PHY-97110-PT SESSION BY LICENSED PT 27 147.583023 10017.8900 67.8797
PHY-97110HM-PT SESSION BY PT ASST 5 14.795100 803.6700 54.3200
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.000000 1000.0000 500.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 126 754.739981 51231.7596 67.8800
TRAN-TRAN-FAMILY TRANSPORTATION 2 102.000000 84.0000 0.8235
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 365 81256.00000 60311.2000 0.7422
Subtotal (Total Children Is Unduplicated) 391 82650.80269 145465.6196 1.7600
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Total 82749.452190 152295.5196 1.8404
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Number of Children (Unduplicated) With at Least One Service 404
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Center 55
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 1806 32014.666100 58694.4500 58694.4500
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 2900 50651.481734 91995.0696 91995.0700
33 83.304356 1606.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4739 82749.452190 152295.5196 150689.5200