CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/15/2012 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 973 4340.750000 160487.5000 36.9723
Subtotal (Total Children Is Unduplicated) 973 4340.750000 160487.5000 36.9723
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 29 57.000000 4275.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 9.500000 712.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 10.000000 750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 13 26.000000 1950.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 18 35.500000 1970.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 100 188.000000 14025.0000 74.6011
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 72 130.000000 9675.0000 74.4231
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 39 76.000000 5700.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 130 248.000000 13708.5000 55.2762
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 17.500000 1312.5000 75.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 197 798.500000 54127.2500 67.7862
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 60 187.750000 9387.5000 50.0000
PHY-97110-PT SESSION BY LICENSED PT 22 95.750000 6499.5100 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 13 69.000000 4683.7200 67.8800
Subtotal (Total Children Is Unduplicated) 92 352.500000 20570.7300 58.3567
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Total 5491.750000 235185.4800 42.8252
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Number of Children (Unduplicated) With at Least One Service 982
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Center 09
Flag Claims Units Chgs Paid
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R 3 1.750000 64.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 5406 5073.250000 219569.4800 0.0000
P 425 409.250000 15273.7500 15316.9750
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
7 5.750000 212.7500 0.0000
Other 3 1.750000 64.7500 0.0000
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Total 5844 5491.750000 235185.4800 15316.9750