CMS/EIP Fiscal Report Center: 57
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:OTHER
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
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 1 1.000000 48.5000 48.5000
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EI Services,Class #03
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 0.500000 33.9400 67.8800
PHY-97110-PT SESSION BY LICENSED PT 3 1.500000 101.8200 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 54.3200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 135.7600 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 5 180.000000 90.0000 0.5000
Subtotal (Total Children Is Unduplicated) 10 186.000000 465.8400 2.5045
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Total 187.000000 514.3400 2.7505
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Number of Children (Unduplicated) With at Least One Service 11
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Center 57
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 2 21.000000 60.0000 60.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 12 166.000000 454.3400 454.3400
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Total 14 187.000000 514.3400 514.3400