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:TPIN
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 5 4.500000 166.5000 37.0000
Subtotal (Total Children Is Unduplicated) 5 4.500000 166.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 0.833300 62.5000 75.0030
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 21.839500 1637.9700 75.0003
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 7.268000 545.1000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 11.487999 861.6000 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 5 5.000000 242.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 27 51.428799 3642.4200 70.8245
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 21 95.571385 6487.4000 67.8802
OCCT-97530HM-OT SESSION BY OT ASST 2 10.000000 543.2000 54.3200
PHY-97110-PT SESSION BY LICENSED PT 9 29.978597 2034.9700 67.8808
PHY-97110HM-PT SESSION BY PT ASST 3 3.211200 174.4400 54.3224
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 47 280.903519 19067.7300 67.8800
Subtotal (Total Children Is Unduplicated) 67 419.664701 28307.7400 67.4532
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Total 475.593500 32116.6600 67.5296
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Number of Children (Unduplicated) With at Least One Service 89
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Center 55
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 13 11.487999 770.4000 657.9000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 4.500000 337.5000 0.0000
T 0 0.000000 0.0000 0.0000
585 459.605501 31008.7600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 601 475.593500 32116.6600 657.9000