CMS/EIP Fiscal Report Center: 09
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 1159 4394.750000 162568.7500 36.9916
Subtotal (Total Children Is Unduplicated) 1159 4394.750000 162568.7500 36.9916
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 29 56.000000 4200.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 14.000000 1050.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 10.000000 750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 18 36.000000 2700.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 19 37.000000 2053.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 151 273.000000 20475.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 120 190.000000 14250.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 60 104.500000 7837.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 258 464.000000 25752.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 38.000000 2850.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 5.000000 242.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 338 1229.500000 82257.5000 66.9032
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 555 3831.000000 191550.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 60 332.250000 22553.1300 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 1 2.000000 108.6400 54.3200
PHY-97110-PT SESSION BY LICENSED PT 115 829.500000 56306.4600 67.8800
PHY-97110HM-PT SESSION BY PT ASST 22 131.000000 7115.9200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 124 708.750000 48109.9500 67.8800
Subtotal (Total Children Is Unduplicated) 749 5834.500000 325744.1000 55.8307
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Total 11458.750000 570570.3500 49.7934
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Number of Children (Unduplicated) With at Least One Service 1253
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Center 09
Flag Claims Units Chgs Paid
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R 5 4.750000 175.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 5471 5641.500000 251646.0800 0.0000
P 317 347.000000 17040.0000 17040.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1874 5465.500000 301708.5200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7667 11458.750000 570570.3500 17040.0000