CMS/EIP Fiscal Report Center: 55
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 402 1192.250000 43761.7500 36.7052
Subtotal (Total Children Is Unduplicated) 402 1192.250000 43761.7500 36.7052
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 2.000000 250.0000 125.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 56.000000 4200.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 24 42.500000 3150.0000 74.1176
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 13.000000 975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 9.000000 499.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 55.000000 4125.0000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 48.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 13 13.000000 630.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.000000 97.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.000000 194.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.000000 145.5000 48.5000
Subtotal (Total Children Is Unduplicated) 77 202.000000 14427.5000 71.4233
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 63 434.000000 21700.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 50 290.000000 19685.2000 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 7 40.000000 2172.8000 54.3200
PHY-97110-PT SESSION BY LICENSED PT 32 167.750000 11352.9300 67.6777
PHY-97110HM-PT SESSION BY PT ASST 14 49.500000 2688.8400 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 108 677.500000 45988.7000 67.8800
Subtotal (Total Children Is Unduplicated) 196 1658.750000 103588.4700 62.4497
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Total 3053.000000 161777.7200 52.9898
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Number of Children (Unduplicated) With at Least One Service 446
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Center 55
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 13 14.000000 490.2500 0.0000
P 1294 1225.000000 47148.2500 47148.2500
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
2095 1814.000000 114139.2200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3402 3053.000000 161777.7200 47148.2500