CMS/EIP Fiscal Report Center: 57
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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 1.813000 87.9300 48.4997
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 11 10.309300 500.0000 48.4999
Subtotal (Total Children Is Unduplicated) 16 23.122300 1288.9300 55.7440
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 8.000000 400.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 8 39.500000 2681.2600 67.8800
PHY-97110-PT SESSION BY LICENSED PT 35 138.000000 9367.4400 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 36 159.250000 10809.8900 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.000000 39.6000 13.2000
Subtotal (Total Children Is Unduplicated) 69 347.750000 23298.1900 66.9970
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Total 370.872300 24587.1200 66.2954
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Number of Children (Unduplicated) With at Least One Service 81
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Center 57
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 2 1.122300 54.4300 54.4300
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 7 11.000000 545.5000 545.5000
183 358.750000 23987.1900 23396.9100
Other 0 0.000000 0.0000 0.0000
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Total 192 370.872300 24587.1200 23996.8400