CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 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-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 56 86.000000 6450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 25.000000 1837.5000 73.5000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 43 69.000000 5175.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 52 79.500000 4412.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 47.000000 3525.0000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 14 65.000000 3250.0000 50.0000
Subtotal (Total Children Is Unduplicated) 148 380.500000 25295.5000 66.4796
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 9.000000 450.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 27 112.000000 7983.4200 71.2805
PHY-97110-PT SESSION BY LICENSED PT 43 225.000000 15985.2700 71.0456
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 85 439.500000 31297.8800 71.2125
Subtotal (Total Children Is Unduplicated) 139 785.500000 55716.5700 70.9313
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Total 1166.000000 81012.0700 69.4786
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Number of Children (Unduplicated) With at Least One Service 280
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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 74 74.500000 5298.3700 5456.7700
D 7 10.000000 655.1300 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
492 1045.000000 72321.0700 71.4600
Other 24 36.500000 2737.5000 0.0000
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Total 597 1166.000000 81012.0700 5528.2300