CMS/EIP Fiscal Report Center: 55
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 562 1841.750000 67876.2500 36.8542
Subtotal (Total Children Is Unduplicated) 562 1841.750000 67876.2500 36.8542
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.500000 337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 60 102.000000 7650.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 54 94.500000 7087.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 18 27.000000 2025.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 33.000000 1831.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 71 106.000000 7950.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 10 10.000000 485.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.000000 242.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 9.000000 436.5000 48.5000
Subtotal (Total Children Is Unduplicated) 141 400.000000 28691.2500 71.7281
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 66 477.500000 23875.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 46 264.750000 17971.2300 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 9 45.500000 2471.5600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 32 154.750000 10504.4300 67.8800
PHY-97110HM-PT SESSION BY PT ASST 17 58.000000 3150.5600 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 127 730.750000 49603.3100 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.750000 9.9000 13.2000
Subtotal (Total Children Is Unduplicated) 237 1732.000000 107585.9900 62.1166
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Total 3973.750000 204153.4900 51.3755
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Number of Children (Unduplicated) With at Least One Service 577
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Center 55
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 59 66.750000 2526.7500 0.0000
P 1939 1877.000000 73350.2500 73350.2500
D 0 0.000000 0.0000 0.0000
S 4 3.500000 129.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2183 2026.500000 128146.9900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4185 3973.750000 204153.4900 73350.2500