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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 561 2098.250000 76793.5000 36.5988
Subtotal (Total Children Is Unduplicated) 561 2098.250000 76793.5000 36.5988
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 25.000000 1875.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 11 21.000000 1537.5000 73.2143
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 21 41.000000 2267.2500 55.2988
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 32.000000 2400.0000 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 89 177.000000 9812.5000 55.4379
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 95 211.500000 15862.5000 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) 151 535.500000 35538.2500 66.3646
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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 345 2276.250000 113812.5000 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) 371 3062.000000 165318.8500 53.9905
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Total 5695.750000 277650.6000 48.7470
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Number of Children (Unduplicated) With at Least One Service 616
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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 166 194.750000 11572.4000 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
3228 3314.750000 178386.4500 200.0000
Other 0 0.000000 0.0000 0.0000
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Total 5865 5695.750000 277650.6000 85751.0000