CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1094 4372.250000 161744.2500 36.9934
Subtotal (Total Children Is Unduplicated) 1094 4372.250000 161744.2500 36.9934
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 10.000000 750.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 31 32.000000 1776.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 38 21.000000 1575.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 1.000000 75.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 52 34.000000 2550.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 166 145.000000 8047.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 7.500000 562.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 90 90.000000 16361.0000 181.7889
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 22 22.000000 2310.0000 105.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 4.000000 194.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.000000 339.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 6.000000 291.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 17 17.000000 824.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 19 19.000000 921.5000 48.5000
Subtotal (Total Children Is Unduplicated) 252 423.500000 37177.5000 87.7863
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 642 5277.000000 263850.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 73 446.250000 30291.4500 67.8800
PHY-97110-PT SESSION BY LICENSED PT 85 399.000000 27084.1200 67.8800
PHY-97110HM-PT SESSION BY PT ASST 4 7.500000 407.4000 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 60 312.750000 21229.4700 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 16.000000 869.1200 54.3200
Subtotal (Total Children Is Unduplicated) 729 6458.500000 343731.5600 53.2216
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Total 11254.250000 542653.3100 48.2176
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Number of Children (Unduplicated) With at Least One Service 1208
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Center 04
Flag Claims Units Chgs Paid
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R 1 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2112 2350.250000 88450.2500 0.0000
P 2103 2122.500000 89174.5000 83843.9000
D 23 26.000000 999.5000 148.0000
S 0 0.000000 0.0000 0.0000
H 1663 5642.500000 287967.4400 287642.2800
T 0 0.000000 0.0000 0.0000
578 1107.750000 75741.9700 0.0000
Other 4 4.500000 291.9000 305.4600
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Total 6484 11254.250000 542653.3100 371939.6400