CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2011 ending 09/30/2011 Date of Report:11/30/2011 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
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 501 1794.500000 66183.7500 36.8814
Subtotal (Total Children Is Unduplicated) 501 1794.500000 66183.7500 36.8814
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 15 30.000000 2250.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 19 36.500000 2025.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 20.000000 1500.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 13.500000 1012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 35 69.500000 3663.0000 52.7050
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 19.500000 1462.5000 75.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.000000 194.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 11 11.000000 533.5000 48.5000
Subtotal (Total Children Is Unduplicated) 83 205.500000 12753.7500 62.0620
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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 82 282.250000 14099.5000 49.9539
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 6 19.000000 950.0000 50.0000
PHY-97110-PT SESSION BY LICENSED PT 6 23.500000 1595.1800 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 9 15.000000 750.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 13.000000 827.7600 63.6738
Subtotal (Total Children Is Unduplicated) 102 364.750000 18522.4400 50.7812
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Total 2364.750000 97459.9400 41.2136
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Number of Children (Unduplicated) With at Least One Service 517
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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 86 77.250000 3456.7100 203.5000
P 2107 1807.750000 72331.5000 72331.5000
D 268 230.750000 12312.4800 0.0000
S 1 0.250000 9.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
256 247.250000 9294.5000 0.0000
Other 1 0.500000 18.5000 0.0000
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Total 2720 2364.750000 97459.9400 72535.0000