CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 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 2 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 4.000000 222.0000 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 28 26.000000 1443.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 17.000000 1275.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 21 21.000000 5880.0000 280.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 5 5.000000 900.0000 180.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 97.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 60 78.500000 10026.5000 127.7261
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 16 119.000000 5950.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 13.000000 882.4400 67.8800
PHY-97110-PT SESSION BY LICENSED PT 8 28.000000 1900.6400 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 0.500000 27.1600 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 28.000000 1900.6400 67.8800
Subtotal (Total Children Is Unduplicated) 34 188.500000 10660.8800 56.5564
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Total 267.000000 20687.3800 77.4808
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Number of Children (Unduplicated) With at Least One Service 87
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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 39 131.000000 7083.9600 3385.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 3.000000 185.7600 185.7600
T 0 0.000000 0.0000 0.0000
80 73.500000 9552.5000 0.0000
Other 34 59.500000 3865.1600 1629.9400
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Total 156 267.000000 20687.3800 5201.2000