CMS/EIP Fiscal Report Center: 54
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 484 751.000000 27787.0000 37.0000
Subtotal (Total Children Is Unduplicated) 484 751.000000 27787.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 13.500000 749.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 20.500000 1537.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 14.500000 1087.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 5.500000 412.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 45.000000 2497.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 13.500000 1012.5000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 2.000000 97.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 145.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 97.0000 48.5000
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 6.000000 291.0000 48.5000
Subtotal (Total Children Is Unduplicated) 56 137.500000 8802.2500 64.0164
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 309 1011.750000 50587.5000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 8 10.000000 500.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 15 46.164200 3133.6300 67.8801
OCCT-97530HM-OT SESSION BY OT ASST 1 1.500000 81.4800 54.3200
PHY-97110-PT SESSION BY LICENSED PT 29 112.885600 7662.6800 67.8800
PHY-97110HM-PT SESSION BY PT ASST 2 6.000000 325.9200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 109.750000 7449.8300 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.000000 54.3200 54.3200
Subtotal (Total Children Is Unduplicated) 364 1299.049800 69795.3600 53.7280
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Total 2187.549800 106384.6100 48.6319
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Number of Children (Unduplicated) With at Least One Service 603
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Center 54
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 179 181.000000 9725.6600 0.0000
P 1306 852.250000 34067.2500 34067.2500
D 1 0.500000 18.5000 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
1191 1153.799800 62573.2000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2677 2187.549800 106384.6100 34067.2500