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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1573 4201.250000 155418.5000 36.9934
Subtotal (Total Children Is Unduplicated) 1573 4201.250000 155418.5000 36.9934
-----------------------------------------------------------------------------------------------------------------------
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 12 17.000000 1275.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 16 23.500000 1762.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 16.000000 888.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 112 135.000000 10125.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 44 58.000000 4350.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 110 140.500000 7797.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 138 204.000000 15300.0000 75.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.000000 242.5000 48.5000
Subtotal (Total Children Is Unduplicated) 255 623.000000 44590.7500 71.5742
-----------------------------------------------------------------------------------------------------------------------
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 536 3405.750000 170287.5000 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) 593 3808.000000 200380.4600 52.6209
-----------------------------------------------------------------------------------------------------------------------
Total 8632.250000 400389.7100 46.3830
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1671
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 2.500000 92.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1579 1132.000000 46342.5000 0.0000
P 4354 3339.250000 128255.7500 128246.5000
D 111 71.750000 2654.7500 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
1503 3741.000000 197398.5400 0.0000
Other 231 320.500000 22824.4200 0.0000
---------------------------------------------------------
Total 7803 8632.250000 400389.7100 128246.5000