CMS/EIP Fiscal Report Center: 09
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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 45 65.500000 4857.5000 74.1603
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 21.000000 1575.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 31 45.500000 3412.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 5.500000 412.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 68 139.500000 10359.6000 74.2624
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8 25.000000 1250.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 71.000000 5072.2400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 43 221.000000 15747.1800 71.2542
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 26 150.000000 10716.0000 71.4400
Subtotal (Total Children Is Unduplicated) 84 467.000000 32785.4200 70.2043
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Total 606.500000 43145.0200 71.1377
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Number of Children (Unduplicated) With at Least One Service 148
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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 1 1.000000 71.4400 0.0000
P 112 112.000000 7958.4000 7958.4000
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
286 493.500000 35115.1800 203.2200
Other 0 0.000000 0.0000 0.0000
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Total 399 606.500000 43145.0200 8161.6200