CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 507 1765.500000 64703.7500 36.6490
Subtotal (Total Children Is Unduplicated) 507 1765.500000 64703.7500 36.6490
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 39.500000 2184.0000 55.2911
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 78 155.000000 8591.5000 55.4290
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 39.500000 2962.5000 75.0000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 103 238.500000 14050.5000 58.9120
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 7.000000 175.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 52 141.250000 7062.5000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 10.000000 500.0000 50.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 12 22.000000 1100.0000 50.0000
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 68 182.250000 8937.5000 49.0398
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Total 2186.250000 87691.7500 40.1106
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Number of Children (Unduplicated) With at Least One Service 530
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Center 53
Flag Claims Units Chgs Paid
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R 8 6.000000 222.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 60 48.000000 1928.0000 9.2500
P 2403 2132.250000 85541.7500 85541.7500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2471 2186.250000 87691.7500 85551.0000