CMS/EIP Fiscal Report Center: 53
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 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 11 22.000000 1650.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.000000 187.5000 62.5000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 18 35.500000 1962.0000 55.2676
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 14.000000 1050.0000 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 49 97.000000 5372.5000 55.3866
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 33.500000 2512.5000 75.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.000000 50.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 2.000000 97.0000 48.5000
Subtotal (Total Children Is Unduplicated) 83 225.000000 14130.0000 62.8000
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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 69 263.750000 13187.5000 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
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 339.4000 67.8800
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 85 309.750000 15401.9000 49.7236
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Total 2308.250000 94550.1500 40.9618
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Number of Children (Unduplicated) With at Least One Service 505
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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
273 276.250000 10238.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2631 2308.250000 94550.1500 72413.5000