CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1152 3710.250000 137279.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1152 3710.250000 137279.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 5.000000 375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 3.500000 262.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 14.000000 777.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 49 25.000000 1875.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 5.000000 375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 64 41.500000 3112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 188 160.500000 8907.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 16.500000 1237.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 101 101.000000 5113.6300 50.6300
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 18 18.000000 586.0800 32.5600
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.000000 242.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 14.000000 679.0000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 6.000000 291.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 12 12.000000 582.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 14 14.000000 679.0000 48.5000
Subtotal (Total Children Is Unduplicated) 266 443.500000 25282.9600 57.0078
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 761 6884.000000 344150.0000 49.9927
OCCT-97530-OT SESSION BY LICENSED OT 39 224.750000 15256.0300 67.8800
PHY-97110-PT SESSION BY LICENSED PT 49 202.750000 13762.6700 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 27 162.750000 10938.1100 67.2080
Subtotal (Total Children Is Unduplicated) 806 7474.250000 384106.8100 51.3907
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Total 11628.000000 546669.0200 47.0132
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Number of Children (Unduplicated) With at Least One Service 1292
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Center 04
Flag Claims Units Chgs Paid
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R 23 31.750000 1174.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 925 1100.500000 42436.7500 0.0000
P 2259 2526.500000 96001.1300 95737.2400
D 1 0.500000 18.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 2132 7136.000000 360621.6400 360217.6600
T 0 0.000000 0.0000 0.0000
593 823.000000 45918.9800 0.0000
Other 6 9.750000 497.2700 321.5200
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Total 5939 11628.000000 546669.0200 456276.4200