CMS/EIP Fiscal Report Center: 09
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-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 21 37.500000 2812.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 10.500000 787.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 13 22.500000 1687.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 17.000000 943.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 129 234.500000 17587.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 55 97.000000 7275.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 44 77.500000 5812.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 101 191.500000 10628.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 73.500000 5512.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 97.0000 48.5000
Subtotal (Total Children Is Unduplicated) 186 767.500000 53443.7500 69.6336
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 74.000000 3700.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 54 228.000000 15476.6400 67.8800
PHY-97110-PT SESSION BY LICENSED PT 87 389.250000 26422.2900 67.8800
PHY-97110HM-PT SESSION BY PT ASST 6 15.500000 841.9600 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 81 372.000000 25251.3600 67.8800
Subtotal (Total Children Is Unduplicated) 162 1078.750000 71692.2500 66.4586
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Total 1846.250000 125136.0000 67.7785
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Number of Children (Unduplicated) With at Least One Service 336
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Center 09
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 64 176.250000 10630.8900 10807.0800
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
1007 1670.000000 114505.1100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1071 1846.250000 125136.0000 10807.0800