CMS/EIP Fiscal Report Center: 54
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-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 6 10.500000 663.5000 63.1905
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 20.000000 1000.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 19 41.072800 2053.6400 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 42.000000 2837.4000 67.5571
PHY-97110-PT SESSION BY LICENSED PT 9 24.449000 1659.6400 67.8817
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 33.500000 2273.9800 67.8800
Subtotal (Total Children Is Unduplicated) 40 162.021800 9874.6600 60.9465
-----------------------------------------------------------------------------------------------------------------------
Total 172.521800 10538.1600 61.0831
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 42
-----------------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 14 9.272800 463.6400 705.6000
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
138 150.999000 9412.0200 0.0000
Other 12 12.250000 662.5000 0.0000
---------------------------------------------------------
Total 164 172.521800 10538.1600 705.6000