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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1143 3880.500000 143578.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1143 3880.500000 143578.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 4.000000 300.0000 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 17 10.500000 787.5000 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 38 36.000000 1998.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 39 21.500000 1612.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 6.000000 450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 109 66.000000 4950.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 263 230.000000 12765.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 20.000000 1500.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 139 139.000000 7037.5700 50.6300
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 20 20.000000 651.2000 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) 382 636.000000 36289.2700 57.0586
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 830 7195.000000 359750.0000 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) 880 7824.750000 402361.8300 51.4217
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Total 12341.250000 582229.6000 47.1775
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Number of Children (Unduplicated) With at Least One Service 1409
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Center 04
Flag Claims Units Chgs Paid
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R 124 71.750000 2654.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2004 2094.250000 80461.0000 0.0000
P 1537 1907.250000 74005.9000 73963.7600
D 1 1.250000 46.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 2323 7490.500000 379091.5400 348468.1600
T 0 0.000000 0.0000 0.0000
622 774.000000 45886.9100 0.0000
Other 3 2.250000 83.2500 0.0000
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Total 6614 12341.250000 582229.6000 422431.9200