CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
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-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 0.500000 37.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.000000 388.5000 55.5000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 52 54.500000 3024.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 23 23.000000 4255.0000 185.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 210.0000 105.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.000000 145.5000 48.5000
Subtotal (Total Children Is Unduplicated) 64 94.500000 8345.7500 88.3148
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 13 77.000000 3850.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 20.000000 1357.6000 67.8800
PHY-97110-PT SESSION BY LICENSED PT 6 22.500000 1527.3000 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 37.500000 2545.5000 67.8800
Subtotal (Total Children Is Unduplicated) 32 157.000000 9280.4000 59.1108
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Total 251.500000 17626.1500 70.0841
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Number of Children (Unduplicated) With at Least One Service 89
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Center 04
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 48 102.500000 6619.5000 8609.5700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 3.000000 203.6400 203.6400
T 0 0.000000 0.0000 0.0000
60 64.000000 5333.7500 0.0000
Other 39 82.000000 5469.2600 5420.7600
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Total 148 251.500000 17626.1500 14233.9700