CMS/EIP Fiscal Report Center: 07
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 1028 3118.000000 115366.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1028 3118.000000 115366.0000 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 10.000000 750.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 35 67.000000 5025.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 50 96.500000 5355.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 95 254.000000 19050.0000 75.0000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 10 10.000000 500.0000 50.0000
Subtotal (Total Children Is Unduplicated) 129 453.500000 31841.7500 70.2133
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 445 3056.250000 152812.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 27.500000 1866.7000 67.8800
PHY-97110-PT SESSION BY LICENSED PT 2 2.000000 135.7600 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.000000 50.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 11 55.000000 3733.4000 67.8800
Subtotal (Total Children Is Unduplicated) 457 3141.750000 158598.3600 50.4809
-----------------------------------------------------------------------------------------------------------------------
Total 6713.250000 305806.1100 45.5526
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1080
-----------------------------------------------------------------------------------------------------------------------
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 8.750000 323.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 144 86.250000 3191.2500 0.0000
P 4728 3285.000000 130439.0000 130429.7500
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
1247 3333.250000 171852.1100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6134 6713.250000 305806.1100 130429.7500