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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1240 4994.000000 184749.0000 36.9942
Subtotal (Total Children Is Unduplicated) 1240 4994.000000 184749.0000 36.9942
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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 80 42.500000 3187.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 2.500000 187.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 66 42.500000 3187.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 258 225.500000 12515.2500 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 126 126.000000 22876.5000 181.5595
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) 345 571.500000 50523.2500 88.4046
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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 12024.000000 579003.8100 48.1540
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Number of Children (Unduplicated) With at Least One Service 1357
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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 2403 2702.750000 102366.7500 0.0000
P 2398 2499.000000 107729.2500 99993.9000
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
608 1148.500000 79621.2200 0.0000
Other 4 4.500000 291.9000 305.4600
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Total 7100 12024.000000 579003.8100 388089.6400