CMS/EIP Fiscal Report Center: 09
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 1130 5277.250000 195166.7500 36.9827
Subtotal (Total Children Is Unduplicated) 1130 5277.250000 195166.7500 36.9827
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 21 36.500000 2737.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 5.500000 412.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 17 32.000000 2400.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 17.500000 971.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 135 221.000000 16575.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 110 158.500000 11887.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 69 116.000000 8700.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 184 336.000000 18648.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 114 179.500000 13462.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.000000 242.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.000000 145.5000 48.5000
Subtotal (Total Children Is Unduplicated) 331 1114.000000 76391.7500 68.5743
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 538 3691.000000 184550.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 41 304.500000 20669.4600 67.8800
PHY-97110-PT SESSION BY LICENSED PT 123 789.500000 53591.2600 67.8800
PHY-97110HM-PT SESSION BY PT ASST 15 81.000000 4399.9200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 125 730.000000 49552.4000 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.2000 13.2000
Subtotal (Total Children Is Unduplicated) 715 5597.000000 312776.2400 55.8828
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Total 11988.250000 584334.7400 48.7423
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Number of Children (Unduplicated) With at Least One Service 1171
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Center 09
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 6926 6704.250000 292948.6500 55.5000
P 98 117.000000 5720.2500 5773.5000
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
1692 5167.000000 285665.8400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 8716 11988.250000 584334.7400 5829.0000