CMS/EIP Fiscal Report Center: 10
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 7 11.000000 825.0000 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 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 13.500000 749.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 88 157.000000 11775.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 46 76.500000 5737.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 29 51.000000 3825.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 123 224.500000 12459.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 56.500000 4237.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 6.000000 291.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 36.0000 36.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.000000 117.0000 39.0000
Subtotal (Total Children Is Unduplicated) 171 609.500000 40765.5000 66.8835
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 8.000000 915.8200 114.4775
OCCT-97530-OT SESSION BY LICENSED OT 72 317.750000 21410.4700 67.3815
OCCT-97530HM-OT SESSION BY OT ASST 6 12.500000 578.7200 46.2976
PHY-97110-PT SESSION BY LICENSED PT 116 398.500000 26480.4200 66.4502
PHY-97110HM-PT SESSION BY PT ASST 1 3.500000 190.1200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 106 388.750000 26297.4300 67.6461
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 11.500000 624.6800 54.3200
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 20.000000 10.0000 0.5000
Subtotal (Total Children Is Unduplicated) 196 1160.500000 76507.6600 65.9265
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Total 1770.000000 117273.1600 66.2560
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Number of Children (Unduplicated) With at Least One Service 353
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Center 10
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 140 260.500000 16224.2500 8738.0000
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
781 1509.500000 101048.9100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 921 1770.000000 117273.1600 8738.0000