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: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 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-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 3.852800 288.9600 75.0000
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 5 8.500000 471.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.311300 323.3500 75.0006
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 12 23.664100 1553.3100 65.6399
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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
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Total 185.685900 11427.9700 61.5446
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Number of Children (Unduplicated) With at Least One Service 48
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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 15 10.584100 561.9900 803.9200
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
144 159.851800 10007.7300 0.0000
Other 14 15.250000 858.2500 0.0000
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Total 173 185.685900 11427.9700 803.9200