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:Program Patients
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 7 9.000000 499.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 0.500000 37.5000 75.0000
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 94 92.000000 5106.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 40 40.000000 7400.0000 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) 110 153.000000 13833.0000 90.4118
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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 310.000000 23113.4000 74.5594
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Number of Children (Unduplicated) With at Least One Service 135
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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 71 123.000000 8673.5000 12929.5100
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
100 102.000000 8767.0000 0.0000
Other 39 82.000000 5469.2600 5420.7600
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Total 211 310.000000 23113.4000 18553.9100