CMS/EIP Fiscal Report Center: 55
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 460 1482.000000 54316.0000 36.6505
Subtotal (Total Children Is Unduplicated) 460 1482.000000 54316.0000 36.6505
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 2.000000 250.0000 125.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 54 93.500000 7012.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 42 75.500000 5625.0000 74.5033
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 23.500000 1762.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 15.000000 832.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 56 83.500000 6262.5000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 48.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 13 13.000000 630.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.000000 97.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.000000 194.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.000000 145.5000 48.5000
Subtotal (Total Children Is Unduplicated) 119 327.000000 23685.5000 72.4327
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 63 434.000000 21700.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 50 290.000000 19685.2000 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 7 40.000000 2172.8000 54.3200
PHY-97110-PT SESSION BY LICENSED PT 32 167.750000 11352.9300 67.6777
PHY-97110HM-PT SESSION BY PT ASST 14 49.500000 2688.8400 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 108 677.500000 45988.7000 67.8800
Subtotal (Total Children Is Unduplicated) 196 1658.750000 103588.4700 62.4497
-----------------------------------------------------------------------------------------------------------------------
Total 3467.750000 181589.9700 52.3654
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 504
-----------------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 28 30.500000 1100.7500 0.0000
P 1543 1529.000000 59397.5000 59397.5000
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
2149 1908.250000 121091.7200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3720 3467.750000 181589.9700 59397.5000