CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2012 ending 03/31/2012 Date of Report:05/15/2012 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 481 2037.250000 74851.0000 36.7412
Subtotal (Total Children Is Unduplicated) 481 2037.250000 74851.0000 36.7412
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 36.500000 2737.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 21 42.000000 2331.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 26.000000 1950.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 10.000000 675.0000 67.5000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 71 141.000000 7825.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 30.000000 2250.0000 75.0000
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
Subtotal (Total Children Is Unduplicated) 104 298.500000 18666.0000 62.5327
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 7.000000 175.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 79 286.500000 14325.0000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 6.000000 300.0000 50.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 10 15.000000 750.0000 50.0000
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 2 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 92 317.500000 15700.0000 49.4488
-----------------------------------------------------------------------------------------------------------------------
Total 2653.250000 109217.0000 41.1635
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 489
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 582 648.000000 26122.5000 0.0000
P 1597 1441.500000 60388.7500 60333.2500
D 186 164.000000 6968.7500 0.0000
S 464 375.250000 14790.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
30 24.000000 928.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2860 2653.250000 109217.0000 60333.2500