CMS/EIP Fiscal Report Center: 09
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: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 20 39.500000 2962.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 13.000000 975.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 14 28.000000 2100.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 21.500000 1193.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 118 218.500000 16387.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 53 98.500000 7387.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 66 115.000000 8625.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 131 248.500000 13791.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 38 67.000000 5025.0000 75.0000
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 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 211 860.500000 59193.0000 68.7891
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 55.000000 2750.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 80.500000 5464.3400 67.8800
PHY-97110-PT SESSION BY LICENSED PT 56 299.250000 20313.0900 67.8800
PHY-97110HM-PT SESSION BY PT ASST 3 5.000000 271.6000 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 90 390.500000 26507.1400 67.8800
Subtotal (Total Children Is Unduplicated) 141 830.250000 55306.1700 66.6139
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Total 1690.750000 114499.1700 67.7209
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Number of Children (Unduplicated) With at Least One Service 334
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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 63 149.000000 9187.6800 9187.6800
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
902 1541.750000 105311.4900 131.2000
Other 0 0.000000 0.0000 0.0000
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Total 965 1690.750000 114499.1700 9318.8800