CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 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 17 33.000000 2475.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 3.000000 225.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 16 30.500000 2287.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 103.000000 7725.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 32 44.500000 3337.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 41 69.000000 5175.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 46 84.500000 4689.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 67 114.500000 8587.5000 75.0000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 97.0000 48.5000
Subtotal (Total Children Is Unduplicated) 134 494.500000 35214.0000 71.2113
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 59.000000 2950.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 18 83.000000 5634.0400 67.8800
PHY-97110-PT SESSION BY LICENSED PT 41 198.500000 13474.1800 67.8800
PHY-97110HM-PT SESSION BY PT ASST 4 20.000000 1086.4000 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 70 366.250000 24861.0500 67.8800
Subtotal (Total Children Is Unduplicated) 119 726.750000 48005.6700 66.0553
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Total 1221.250000 83219.6700 68.1430
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Number of Children (Unduplicated) With at Least One Service 233
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Center 09
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 10 43.000000 2579.1200 2579.1200
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
669 1178.250000 80640.5500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 679 1221.250000 83219.6700 2579.1200