CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2012 ending 03/31/2012 Date of Report:05/16/2012 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 557 2450.750000 90113.5000 36.7698
Subtotal (Total Children Is Unduplicated) 557 2450.750000 90113.5000 36.7698
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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 9 18.000000 1350.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 27 54.000000 2997.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 40.000000 3000.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 12.000000 825.0000 68.7500
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 120 237.500000 13181.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 112 220.000000 16500.0000 75.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 145.5000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.000000 50.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.000000 291.0000 48.5000
Subtotal (Total Children Is Unduplicated) 165 634.000000 41527.2500 65.5004
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 12 16.000000 400.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 365 2286.000000 114300.0000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 4 7.000000 350.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 116.000000 7874.0800 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 1 12.000000 651.8400 54.3200
PHY-97110-PT SESSION BY LICENSED PT 34 225.500000 15306.9400 67.8800
PHY-97110HM-PT SESSION BY PT ASST 11 42.000000 2281.4400 54.3200
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 10 15.000000 750.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 34 166.500000 11302.0200 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.2000 13.2000
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 2 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 390 2890.000000 153379.5200 53.0725
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Total 5974.750000 285020.2700 47.7041
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Number of Children (Unduplicated) With at Least One Service 609
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Center 53
Flag Claims Units Chgs Paid
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R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 678 785.000000 31469.5000 0.0000
P 1840 1739.000000 73608.5000 73534.5000
D 221 205.750000 8526.5000 0.0000
S 514 430.500000 17134.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2766 2814.000000 154262.5200 271.5200
Other 0 0.000000 0.0000 0.0000
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Total 6020 5974.750000 285020.2700 73806.0200