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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.250000 9.2500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 25 80.000000 2987.7500 37.3469
TCON-TCON-TRANSITION CONFERENCE 1 1.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 25 82.250000 2997.0000 36.4377
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 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 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 18.500000 1387.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 48.500000 2691.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 46.194130 3464.5598 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 97.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 97.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.000000 145.5000 48.5000
Subtotal (Total Children Is Unduplicated) 43 138.194130 9155.3098 66.2496
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 0.150000 86.7400 578.2667
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 20 106.449000 5322.4500 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 41.973323 2849.1492 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 3 32.000000 1738.2400 54.3200
PHY-97110-PT SESSION BY LICENSED PT 21 147.250000 9995.3300 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 20 76.113730 5166.6000 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 114.000000 57.0000 0.5000
Subtotal (Total Children Is Unduplicated) 55 518.936053 25265.5092 48.6871
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Total 739.380183 37417.8190 50.6070
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Number of Children (Unduplicated) With at Least One Service 101
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Center 53
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 0 0.000000 0.0000 0.0000
P 1 0.449000 22.4500 22.4500
D 5 3.000000 124.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 14 14.000000 771.5200 771.5200
T 15 15.000000 839.4000 839.4000
526 701.931183 35410.4490 0.0000
Other 5 5.000000 250.0000 0.0000
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Total 566 739.380183 37417.8190 1633.3700