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:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 0.647200 48.5400 75.0000
Subtotal (Total Children Is Unduplicated) 1 0.647200 48.5400 75.0000
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 0.500000 25.0000 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 2 6.361600 318.0800 50.0000
PHY-97110HM-PT SESSION BY PT ASST 2 14.000000 760.4800 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 3.250000 220.6100 67.8800
Subtotal (Total Children Is Unduplicated) 8 25.111600 1374.1700 54.7225
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Total 25.758800 1422.7100 55.2320
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Number of Children (Unduplicated) With at Least One Service 9
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Center 54
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 0 0.000000 0.0000 0.0000
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
30 25.758800 1422.7100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 30 25.758800 1422.7100 0.0000