CMS/EIP Fiscal Report Center: 57
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 725 2273.500000 84119.5000 37.0000
Subtotal (Total Children Is Unduplicated) 725 2273.500000 84119.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 11.000000 825.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 11.000000 610.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 96 109.500000 8212.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 131 170.000000 9435.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 68 92.000000 6900.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.000000 242.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.000000 291.0000 48.5000
Subtotal (Total Children Is Unduplicated) 162 415.500000 27315.0000 65.7401
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 481 4498.000000 224900.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 66 446.250000 30291.4500 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 3 11.500000 624.6800 54.3200
PHY-97110-PT SESSION BY LICENSED PT 56 326.250000 22145.8500 67.8800
PHY-97110HM-PT SESSION BY PT ASST 5 31.750000 1724.6600 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 93 576.500000 39132.8200 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 35.500000 1928.3600 54.3200
Subtotal (Total Children Is Unduplicated) 597 5925.750000 320747.8200 54.1278
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Total 8614.750000 432182.3200 50.1677
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Number of Children (Unduplicated) With at Least One Service 845
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Center 57
Flag Claims Units Chgs Paid
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R 33 22.500000 832.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1710 1355.250000 55035.5000 0.0000
P 1308 1297.250000 54834.5000 54788.2500
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
1747 5939.750000 321479.8200 321329.8200
Other 0 0.000000 0.0000 0.0000
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Total 4798 8614.750000 432182.3200 376118.0700