CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2012 ending 09/30/2012 Date of Report:11/15/2012 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 471 1937.750000 71136.5000 36.7109
Subtotal (Total Children Is Unduplicated) 471 1937.750000 71136.5000 36.7109
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 38.000000 2850.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 26 50.500000 2802.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 51 100.000000 5550.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 28.000000 2100.0000 75.0000
Subtotal (Total Children Is Unduplicated) 80 236.000000 14765.2500 62.5646
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 8.000000 200.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 112 519.250000 25937.5000 49.9519
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 5 10.750000 537.5000 50.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 8 22.000000 1100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 125 560.000000 27775.0000 49.5982
-----------------------------------------------------------------------------------------------------------------------
Total 2733.750000 113676.7500 41.5827
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 477
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 280 242.500000 10327.7500 9.2500
P 2666 2452.000000 101906.7500 101838.2500
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
34 37.750000 1386.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2981 2733.750000 113676.7500 101847.5000