CMS/EIP Fiscal Report Center: 57
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 544 1576.250000 58321.2500 37.0000
Subtotal (Total Children Is Unduplicated) 544 1576.250000 58321.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 8.000000 600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 11.500000 638.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 123 157.500000 11812.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 155 243.500000 13514.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 51 73.000000 5475.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.000000 291.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.000000 291.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 9.000000 436.5000 48.5000
Subtotal (Total Children Is Unduplicated) 191 523.500000 33733.5000 64.4384
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 452 4131.000000 206550.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 54 415.250000 28187.1700 67.8800
PHY-97110-PT SESSION BY LICENSED PT 48 277.750000 18853.6700 67.8800
PHY-97110HM-PT SESSION BY PT ASST 6 28.500000 1548.1200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 70 439.000000 29799.3200 67.8800
Subtotal (Total Children Is Unduplicated) 542 5291.500000 284938.2800 53.8483
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Total 7391.250000 376993.0300 51.0053
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Number of Children (Unduplicated) With at Least One Service 738
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Center 57
Flag Claims Units Chgs Paid
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R 2 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1152 1090.250000 45684.7500 0.0000
P 872 971.250000 44277.7500 44277.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 7.750000 495.7500 0.0000
T 3 9.000000 450.0000 450.0000
1556 5312.000000 286047.7800 285482.9800
Other 0 0.000000 0.0000 0.0000
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Total 3590 7391.250000 376993.0300 330210.7300