CMS/EIP Fiscal Report Center: 10
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 1765 5181.750000 191724.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1765 5181.750000 191724.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 15 25.000000 1875.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 12.000000 900.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 6.500000 487.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 7.000000 525.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 25.500000 1415.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 155 257.500000 19312.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 72 111.000000 8325.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 86 134.500000 10087.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 166 273.500000 15179.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 116 148.500000 11137.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.000000 194.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.000000 291.0000 48.5000
Subtotal (Total Children Is Unduplicated) 323 1011.000000 69729.5000 68.9708
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 577 5043.000000 252030.0000 49.9762
OCCT-97530-OT SESSION BY LICENSED OT 69 489.000000 33193.3200 67.8800
PHY-97110-PT SESSION BY LICENSED PT 69 363.500000 24674.3800 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 63 402.500000 27321.7000 67.8800
Subtotal (Total Children Is Unduplicated) 677 6298.000000 337219.4000 53.5439
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Total 12490.750000 598673.6500 47.9294
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Number of Children (Unduplicated) With at Least One Service 1806
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Center 10
Flag Claims Units Chgs Paid
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R 79 48.250000 1785.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 8243 5496.750000 215247.5000 0.0000
P 406 633.000000 43679.7500 43519.7500
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
2096 6308.750000 337680.1500 0.0000
Other 3 4.000000 281.0000 0.0000
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Total 10827 12490.750000 598673.6500 43519.7500