CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 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 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 30.000000 2250.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 10.000000 750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 23 55.000000 3936.1500 71.5664
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.000000 1347.8800 673.9400
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 4.000000 200.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 5.000000 50.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 6.000000 428.6400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 3 7.000000 322.0600 46.0086
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 72.250000 5086.5300 70.4018
Subtotal (Total Children Is Unduplicated) 39 96.250000 7435.1100 77.2479
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Total 151.250000 11371.2600 75.1819
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Number of Children (Unduplicated) With at Least One Service 58
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Center 02
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 80 85.000000 5406.1300 0.0000
55 66.250000 5965.1300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 135 151.250000 11371.2600 0.0000