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:OTHER
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 2 1.250000 46.2500 37.0000
Subtotal (Total Children Is Unduplicated) 2 1.250000 46.2500 37.0000
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Screening, Eval, and Assessment,Class #02
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 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 5 11.500000 777.5000 67.6087
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EI Services,Class #03
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 0.500000 33.9400 67.8800
PHY-97110-PT SESSION BY LICENSED PT 3 1.500000 101.8200 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 54.3200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 135.7600 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 5 180.000000 90.0000 0.5000
Subtotal (Total Children Is Unduplicated) 10 186.000000 465.8400 2.5045
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Total 198.750000 1289.5900 6.4885
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Number of Children (Unduplicated) With at Least One Service 17
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Center 57
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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 2 21.000000 60.0000 60.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
10 11.750000 775.2500 0.0000
Other 12 166.000000 454.3400 454.3400
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Total 24 198.750000 1289.5900 514.3400