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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1272 4194.750000 155205.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1272 4194.750000 155205.7500 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 15 15.000000 832.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 71 36.000000 2700.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 7.500000 562.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 79 49.500000 3712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 259 214.000000 11877.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 19.500000 1462.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 140 140.000000 7088.2000 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) 343 561.500000 32119.7800 57.2035
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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 12230.500000 571432.3400 46.7219
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Number of Children (Unduplicated) With at Least One Service 1414
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Center 04
Flag Claims Units Chgs Paid
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R 25 34.500000 1276.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 999 1219.500000 47168.5000 0.0000
P 2501 2882.500000 109750.2600 109477.1200
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
714 947.750000 52099.6700 0.0000
Other 6 9.750000 497.2700 321.5200
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Total 6378 12230.500000 571432.3400 470016.3000