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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 511 847.750000 31366.7500 37.0000
Subtotal (Total Children Is Unduplicated) 511 847.750000 31366.7500 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 4 6.000000 450.0000 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 11 18.000000 999.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 37.000000 2775.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 28.500000 2137.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 6.500000 487.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 44 71.500000 3968.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 17.000000 1275.0000 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) 79 208.500000 13522.7500 64.8573
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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 2355.299800 114684.8600 48.6923
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Number of Children (Unduplicated) With at Least One Service 631
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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 196 209.250000 11584.4100 0.0000
P 1393 945.000000 37526.7500 37526.7500
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
1225 1200.549800 65555.2000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2815 2355.299800 114684.8600 37526.7500