CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
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 1025 4114.250000 152190.2500 36.9910
Subtotal (Total Children Is Unduplicated) 1025 4114.250000 152190.2500 36.9910
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 20 39.500000 2962.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 9.000000 675.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 14 27.000000 2025.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 19.500000 1082.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 74 145.000000 10875.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 83 153.000000 11475.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 69 129.500000 9712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 180 340.000000 18870.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 10.500000 787.5000 75.0000
Subtotal (Total Children Is Unduplicated) 227 875.000000 58614.7500 66.9883
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 14 60.000000 3000.0000 50.0000
PHY-97110-PT SESSION BY LICENSED PT 24 127.250000 8637.7300 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 5.000000 271.6000 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 31 87.000000 5905.5600 67.8800
Subtotal (Total Children Is Unduplicated) 67 279.250000 17814.8900 63.7955
-----------------------------------------------------------------------------------------------------------------------
Total 5268.500000 228619.8900 43.3937
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1038
-----------------------------------------------------------------------------------------------------------------------
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.500000 92.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 5421 5261.750000 228339.2600 0.0000
P 3 3.250000 120.2500 120.2500
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
1 1.000000 67.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5427 5268.500000 228619.8900 120.2500