CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 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 1298 4658.500000 172264.7500 36.9786
Subtotal (Total Children Is Unduplicated) 1298 4658.500000 172264.7500 36.9786
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 2.500000 187.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 21 21.000000 1575.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 23 21.500000 1193.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 57 37.000000 2775.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 9.500000 712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 80 50.500000 3787.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 230 203.000000 11266.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 166 148.000000 11100.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 6.000000 303.7800 50.6300
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 3 3.000000 79.3500 26.4500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 11 11.000000 352.9300 32.0845
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 48.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 14.000000 679.0000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 8 8.000000 388.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 18 18.000000 873.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 9.000000 436.5000 48.5000
Subtotal (Total Children Is Unduplicated) 356 567.500000 36095.8100 63.6050
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 5.000000 125.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 832 7617.250000 380662.5000 49.9737
OCCT-97530-OT SESSION BY LICENSED OT 67 378.000000 25658.6400 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 11 69.500000 3775.2400 54.3200
PHY-97110-PT SESSION BY LICENSED PT 44 193.750000 13151.7500 67.8800
PHY-97110HM-PT SESSION BY PT ASST 15 83.500000 4535.7200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 39 198.000000 13440.2400 67.8800
Subtotal (Total Children Is Unduplicated) 902 8545.000000 441349.0900 51.6500
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Total 13771.000000 649709.6500 47.1796
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Number of Children (Unduplicated) With at Least One Service 1476
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Center 04
Flag Claims Units Chgs Paid
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R 33 27.500000 1853.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1855 2331.250000 89373.7500 0.0000
P 1980 2458.250000 94828.5000 94864.2400
D 0 0.000000 0.0000 0.0000
S 2 1.250000 46.2500 0.0000
H 2443 8141.250000 413609.8000 297069.7200
T 0 0.000000 0.0000 0.0000
590 801.750000 49529.0200 0.0000
Other 6 9.750000 468.8300 237.5800
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Total 6909 13771.000000 649709.6500 392171.5400