CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2013 ending 03/31/2013 Date of Report:05/17/2013 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 1044 3549.500000 131331.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1044 3549.500000 131331.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 3.500000 262.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 2.500000 187.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 16 10.000000 750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 35 33.500000 1859.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 15.000000 1125.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 5.500000 412.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 86 54.000000 4050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 204 181.000000 10045.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 16.000000 1200.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 113 113.000000 5721.1900 50.6300
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 19 19.000000 618.6400 32.5600
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 12 13.000000 630.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 19 19.000000 921.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 7 7.000000 339.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 13 13.000000 630.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 23 23.000000 1115.5000 48.5000
Subtotal (Total Children Is Unduplicated) 316 533.500000 30282.0800 56.7612
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 829 7182.000000 359100.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 56 279.250000 18955.4900 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 1 3.000000 162.9600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 46 184.500000 12523.8600 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 4.000000 217.2800 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 34 156.000000 10589.2800 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 3.000000 162.9600 54.3200
Subtotal (Total Children Is Unduplicated) 879 7811.750000 401711.8300 51.4241
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Total 11894.750000 563325.4100 47.3592
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Number of Children (Unduplicated) With at Least One Service 1296
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Center 04
Flag Claims Units Chgs Paid
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R 112 62.500000 2312.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1818 1897.250000 72881.2500 0.0000
P 1416 1735.000000 66813.6700 66779.3200
D 1 1.250000 46.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 2320 7477.500000 378441.5400 348018.1600
T 0 0.000000 0.0000 0.0000
550 719.000000 42746.9500 0.0000
Other 3 2.250000 83.2500 0.0000
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Total 6220 11894.750000 563325.4100 414797.4800