CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2012 ending 06/30/2012 Date of Report:08/16/2012 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 533 2169.250000 80032.0000 36.8939
Subtotal (Total Children Is Unduplicated) 533 2169.250000 80032.0000 36.8939
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 32.000000 2400.0000 75.0000
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 4 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 38.000000 2109.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 22.000000 1650.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 12.000000 900.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 13.000000 975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 91 175.000000 9712.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 50.000000 3674.0000 73.4800
Subtotal (Total Children Is Unduplicated) 126 350.000000 22020.5000 62.9157
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 9.000000 225.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 81 298.000000 14900.0000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 5 10.000000 500.0000 50.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 11 21.500000 1075.0000 50.0000
Subtotal (Total Children Is Unduplicated) 97 338.500000 16700.0000 49.3353
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Total 2857.750000 118752.5000 41.5545
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Number of Children (Unduplicated) With at Least One Service 538
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Center 53
Flag Claims Units Chgs Paid
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R 2 2.500000 133.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 755 642.250000 23834.5000 37.0000
P 2210 2213.000000 94784.7500 94747.2500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2967 2857.750000 118752.5000 94784.2500