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:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 5.000000 185.0000 37.0000
Subtotal (Total Children Is Unduplicated) 3 5.000000 185.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 8.000000 600.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 14.000000 1050.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 16.000000 888.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 22.000000 1575.0000 71.5909
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 97.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.000000 291.0000 48.5000
Subtotal (Total Children Is Unduplicated) 28 76.000000 5074.5000 66.7697
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.000000 483.0600 241.5300
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 16 54.372200 2718.6100 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 1.000000 50.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 114.000000 7738.3200 67.8800
PHY-97110-PT SESSION BY LICENSED PT 20 129.063640 8760.8400 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.000000 50.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 82.337650 5589.0797 67.8800
Subtotal (Total Children Is Unduplicated) 47 383.773490 25389.9097 66.1586
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Total 464.773490 30649.4097 65.9448
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Number of Children (Unduplicated) With at Least One Service 70
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Center 53
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 1 1.000000 50.0000 0.0000
P 5 2.372200 118.6100 118.6100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 17 17.000000 991.5400 991.5400
T 23 23.000000 1328.8000 1328.8000
395 421.401290 28160.4597 275.0000
Other 0 0.000000 0.0000 0.0000
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Total 441 464.773490 30649.4097 2713.9500