CMS/EIP Fiscal Report Center: 09
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 1141 4913.000000 181660.7500 36.9755
Subtotal (Total Children Is Unduplicated) 1141 4913.000000 181660.7500 36.9755
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 41 79.500000 5962.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 15.500000 1162.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 12.000000 900.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 15 29.500000 2212.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 27 53.000000 2941.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 198 351.000000 26250.0000 74.7863
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 114 189.500000 14137.5000 74.6042
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 70 132.500000 9937.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 232 425.000000 23532.0000 55.3694
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 31.000000 2325.0000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 97.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 346 1322.500000 89555.0000 67.7164
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 381 2814.750000 140737.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 77 462.000000 31360.5600 67.8800
PHY-97110-PT SESSION BY LICENSED PT 131 731.500000 49654.2200 67.8800
PHY-97110HM-PT SESSION BY PT ASST 8 48.000000 2607.3600 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 173 1154.000000 78333.5200 67.8800
Subtotal (Total Children Is Unduplicated) 587 5210.250000 302693.1600 58.0957
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Total 11445.750000 573908.9100 50.1417
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Number of Children (Unduplicated) With at Least One Service 1178
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Center 09
Flag Claims Units Chgs Paid
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R 3 1.750000 64.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 6049 6091.750000 273080.4800 0.0000
P 471 483.750000 18239.8800 18196.7250
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
1607 4866.750000 282459.0500 0.0000
Other 3 1.750000 64.7500 0.0000
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Total 8133 11445.750000 573908.9100 18196.7250