CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
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 1433 3791.500000 140257.7500 36.9927
Subtotal (Total Children Is Unduplicated) 1433 3791.500000 140257.7500 36.9927
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 16 21.000000 2625.0000 125.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 10.000000 750.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 16.500000 1237.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 88 109.000000 8175.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 35 45.000000 3375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 89 116.000000 6438.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 107 163.000000 12225.0000 75.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.000000 242.5000 48.5000
Subtotal (Total Children Is Unduplicated) 204 496.500000 35698.0000 71.8993
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 8 42.000000 7013.6100 166.9907
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 30.000000 733.5000 24.4500
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 533 3382.750000 169137.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 67.8800 67.8800
PHY-97110-PT SESSION BY LICENSED PT 17 66.750000 4530.9900 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 4.000000 200.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 258.500000 17546.9800 67.8800
Subtotal (Total Children Is Unduplicated) 590 3785.000000 199230.4600 52.6368
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Total 8073.000000 375186.2100 46.4742
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Number of Children (Unduplicated) With at Least One Service 1529
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Center 01
Flag Claims Units Chgs Paid
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R 2 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1439 1011.500000 41104.7500 0.0000
P 3962 3008.250000 115234.7500 115234.7500
D 98 58.500000 2164.5000 0.0000
S 21 24.000000 2775.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.250000 46.2500 0.0000
1493 3713.500000 195950.0400 0.0000
Other 178 254.000000 17836.9200 0.0000
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Total 7194 8073.000000 375186.2100 115234.7500