CMS/EIP Fiscal Report Center: 05
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 473 1683.250000 62280.2500 37.0000
Subtotal (Total Children Is Unduplicated) 473 1683.250000 62280.2500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 36.500000 2737.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 10.500000 750.0000 71.4286
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 7.500000 562.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 53 65.500000 4912.5000 75.0000
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 3 3.000000 218.3400 72.7800
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 2 2.000000 100.3000 50.1500
SCREEN-T1023-INTERDISCIPLINARY SCREENING 5 5.000000 250.0000 50.0000
Subtotal (Total Children Is Unduplicated) 69 135.500000 9924.1400 73.2409
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 40 99.500000 4975.0000 50.0000
Subtotal (Total Children Is Unduplicated) 41 102.500000 5050.0000 49.2683
-----------------------------------------------------------------------------------------------------------------------
Total 1921.250000 77254.3900 40.2105
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 481
-----------------------------------------------------------------------------------------------------------------------
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2977 1755.750000 67568.3900 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 0 0.000000 0.0000 0.0000
158 165.500000 9686.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3135 1921.250000 77254.3900 0.0000