CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2011 ending 09/30/2011 Date of Report:12/01/2011 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 483 1725.250000 63603.0000 36.8660
Subtotal (Total Children Is Unduplicated) 483 1725.250000 63603.0000 36.8660
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 38.500000 2136.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 59 117.000000 6299.2500 53.8397
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 41.000000 3075.0000 75.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 145.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 92 214.500000 12755.0000 59.4639
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 7 12.000000 300.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 65 214.250000 10699.5000 49.9393
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 6 19.000000 950.0000 50.0000
PHY-97110-PT SESSION BY LICENSED PT 3 3.500000 237.5800 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 9 13.000000 650.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 67.8800 67.8800
Subtotal (Total Children Is Unduplicated) 84 262.750000 12904.9600 49.1150
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Total 2202.500000 89262.9600 40.5280
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Number of Children (Unduplicated) With at Least One Service 519
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Center 53
Flag Claims Units Chgs Paid
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R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 96 86.750000 3884.2100 203.5000
P 2368 2114.750000 85341.7500 85341.7500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2465 2202.500000 89262.9600 85545.2500