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
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 534 2183.250000 80550.0000 36.8945
Subtotal (Total Children Is Unduplicated) 534 2183.250000 80550.0000 36.8945
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 34.000000 2550.0000 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 7 12.000000 900.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 25 46.000000 2553.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 31.500000 2362.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 17.000000 1275.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 17.000000 1275.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 99 190.000000 10545.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 98 185.000000 13799.0000 74.5892
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 97.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.000000 97.0000 48.5000
Subtotal (Total Children Is Unduplicated) 141 538.500000 35603.5000 66.1161
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 4 10.000000 696.5400 69.6540
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 13.000000 325.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 345 2190.250000 109512.5000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 6 12.000000 600.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 14 108.000000 7331.0400 67.8800
PHY-97110-PT SESSION BY LICENSED PT 27 210.750000 14305.7100 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 11 21.500000 1075.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 14 83.500000 5667.9800 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.000000 26.4000 13.2000
Subtotal (Total Children Is Unduplicated) 370 2651.000000 139540.1700 52.6368
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Total 5372.750000 255693.6700 47.5908
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Number of Children (Unduplicated) With at Least One Service 584
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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 1 2.000000 150.0000 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
2424 2470.500000 134391.1700 0.0000
Other 38 42.500000 2400.0000 0.0000
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Total 5430 5372.750000 255693.6700 94784.2500