CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2013 ending 03/31/2013 Date of Report:05/17/2013 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-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 5.000000 277.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 0.500000 37.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 48 43.500000 2414.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 42 33.500000 2512.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 39 39.000000 10920.0000 280.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 180.0000 180.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 97.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.000000 242.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 8.000000 388.0000 48.5000
Subtotal (Total Children Is Unduplicated) 111 140.000000 17256.7500 123.2625
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 19 96.000000 4800.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 15.500000 1052.1400 67.8800
PHY-97110-PT SESSION BY LICENSED PT 12 56.500000 3835.2200 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 35.000000 2375.8000 67.8800
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 1 60.000000 30.0000 0.5000
Subtotal (Total Children Is Unduplicated) 43 263.000000 12093.1600 45.9816
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Total 403.000000 29349.9100 72.8286
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Number of Children (Unduplicated) With at Least One Service 139
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Center 04
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 47 167.000000 7465.6200 7300.8000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 7 9.000000 448.5000 83.9400
T 0 0.000000 0.0000 0.0000
117 107.500000 13774.2500 0.0000
Other 59 119.500000 7661.5400 7661.5400
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Total 230 403.000000 29349.9100 15046.2800