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:TPIN
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 5 26.000000 943.5000 36.2885
Subtotal (Total Children Is Unduplicated) 5 26.000000 943.5000 36.2885
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 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 1 2.000000 150.0000 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 1 0.327800 24.5850 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
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 37 74.500000 4134.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 50.000000 3750.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.000000 194.0000 48.5000
Subtotal (Total Children Is Unduplicated) 51 152.827800 9772.3350 63.9434
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 42 170.250000 8550.0000 50.2203
OCCT-97530-OT SESSION BY LICENSED OT 5 38.000000 2579.4400 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 3 28.000000 1520.9600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 17 110.000000 7466.8000 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 4.000000 200.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 11 52.331525 3552.2645 67.8800
Subtotal (Total Children Is Unduplicated) 61 407.581525 24119.4645 59.1770
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Total 586.409325 34835.2995 59.4044
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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 22 23.000000 1305.7800 1305.7800
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 23 23.000000 1221.5200 1221.5200
477 539.909325 32282.9995 0.0000
Other 1 0.500000 25.0000 0.0000
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Total 523 586.409325 34835.2995 2527.3000