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
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 492 1773.500000 65018.2500 36.6610
Subtotal (Total Children Is Unduplicated) 492 1773.500000 65018.2500 36.6610
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 23.000000 1725.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 17.000000 1237.5000 72.7941
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 19 37.000000 2045.2500 55.2770
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 16.000000 1200.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 16.000000 1200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 55 109.000000 6038.5000 55.3991
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 61 141.500000 10612.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 145.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 97.0000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.000000 50.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 6.000000 291.0000 48.5000
Subtotal (Total Children Is Unduplicated) 103 371.500000 24642.2500 66.3318
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 9 18.000000 450.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 343 2265.250000 113262.5000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 5 17.000000 850.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 26 210.750000 14305.7100 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 1 13.000000 706.1600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 33 257.000000 17445.1600 67.8800
PHY-97110HM-PT SESSION BY PT ASST 2 11.000000 597.5200 54.3200
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 12 22.000000 1100.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 42 235.000000 15951.8000 67.8800
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 369 3051.000000 164768.8500 54.0049
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Total 5196.000000 254429.3500 48.9664
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Number of Children (Unduplicated) With at Least One Service 546
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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 53 40.500000 1613.5000 9.2500
P 2141 1810.750000 72404.2500 72404.2500
D 156 174.750000 10072.4000 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
3125 3164.000000 170117.2000 200.0000
Other 0 0.000000 0.0000 0.0000
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Total 5483 5196.000000 254429.3500 72613.5000