CMS/EIP Fiscal Report Center: 10
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 1504 5791.000000 214267.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1504 5791.000000 214267.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 20 31.500000 2362.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 15.000000 1125.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 11.500000 862.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 14.500000 1087.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 29 53.000000 2941.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 138 252.500000 18937.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 70 103.500000 7762.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 59 98.000000 7350.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 189 339.000000 18814.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 99 123.000000 9225.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.000000 291.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 145.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.000000 242.5000 48.5000
Subtotal (Total Children Is Unduplicated) 304 1055.500000 71147.5000 67.4064
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 286 2674.000000 133700.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 104 359.250000 24385.8900 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 16 38.000000 2064.1600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 206 692.250000 46989.9300 67.8800
PHY-97110HM-PT SESSION BY PT ASST 2 2.500000 135.8000 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 163 671.000000 45547.4800 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 10 21.500000 1167.8800 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.2000 13.2000
Subtotal (Total Children Is Unduplicated) 560 4459.500000 254004.3400 56.9580
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Total 11306.000000 539418.8400 47.7108
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Number of Children (Unduplicated) With at Least One Service 1525
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Center 10
Flag Claims Units Chgs Paid
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R 47 24.250000 1011.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1575 1648.500000 92813.5000 6669.2500
P 8248 5082.250000 188043.2500 188043.2500
D 0 0.000000 0.0000 0.0000
S 91 77.250000 2858.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1676 4473.750000 254692.5900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11637 11306.000000 539418.8400 194712.5000