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
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 1136 4470.000000 165353.0000 36.9917
Subtotal (Total Children Is Unduplicated) 1136 4470.000000 165353.0000 36.9917
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 22 43.500000 3262.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 15.500000 1162.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 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 17 32.500000 1803.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 120 231.500000 17362.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 123 218.500000 16387.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 84 156.500000 11737.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 259 484.500000 26889.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 21.500000 1612.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.000000 291.0000 48.5000
Subtotal (Total Children Is Unduplicated) 335 1244.500000 83044.0000 66.7288
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 542 3626.500000 181325.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 60 386.500000 26235.6200 67.8800
PHY-97110-PT SESSION BY LICENSED PT 115 836.250000 56764.6500 67.8800
PHY-97110HM-PT SESSION BY PT ASST 8 56.000000 3041.9200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 107 613.000000 41610.4400 67.8800
Subtotal (Total Children Is Unduplicated) 725 5518.250000 308977.6300 55.9920
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Total 11232.750000 557374.6300 49.6205
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Number of Children (Unduplicated) With at Least One Service 1212
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Center 09
Flag Claims Units Chgs Paid
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R 2 2.500000 92.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 5859 5979.000000 265543.2600 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
1782 5248.000000 291618.6200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7646 11232.750000 557374.6300 120.2500