CMS/EIP Fiscal Report Center: 57
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 733 3035.000000 112295.0000 37.0000
Subtotal (Total Children Is Unduplicated) 733 3035.000000 112295.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 13.000000 975.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 18.500000 1026.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 140 157.000000 11775.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 159 234.500000 13014.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 25.500000 1912.5000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 12 12.000000 582.0000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 8 8.000000 388.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 97.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 15 15.000000 727.5000 48.5000
Subtotal (Total Children Is Unduplicated) 197 489.000000 30761.0000 62.9059
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 483 4351.750000 217587.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 61 398.500000 27050.1800 67.8800
PHY-97110-PT SESSION BY LICENSED PT 68 299.500000 20330.0600 67.8800
PHY-97110HM-PT SESSION BY PT ASST 6 31.500000 1711.0800 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 91 497.000000 33736.3600 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 13.500000 733.3200 54.3200
Subtotal (Total Children Is Unduplicated) 577 5591.750000 301148.5000 53.8559
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Total 9115.750000 444204.5000 48.7293
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Number of Children (Unduplicated) With at Least One Service 822
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Center 57
Flag Claims Units Chgs Paid
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R 83 88.500000 3274.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1242 1310.500000 58766.7500 0.0000
P 2071 2014.000000 74555.0000 74475.5800
D 1 2.000000 74.0000 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
1824 5700.750000 307534.2500 302943.0000
Other 0 0.000000 0.0000 0.0000
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Total 5221 9115.750000 444204.5000 377418.5800