CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2012 ending 09/30/2012 Date of Report:11/16/2012 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 2259.250000 83004.2500 36.7397
Subtotal (Total Children Is Unduplicated) 534 2259.250000 83004.2500 36.7397
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 21 40.000000 3000.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 13.000000 975.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 28 53.500000 2969.2500 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 6 11.500000 862.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 89 171.000000 9490.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 83 160.500000 12037.5000 75.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 7.000000 339.5000 48.5000
Subtotal (Total Children Is Unduplicated) 135 467.500000 30499.2500 65.2390
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 10 18.000000 450.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 330 2060.000000 102975.0000 49.9879
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 5 10.750000 537.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 12.000000 814.5600 67.8800
PHY-97110-PT SESSION BY LICENSED PT 21 111.000000 7534.6800 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 54.3200 54.3200
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 8 22.000000 1100.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 18 94.000000 6380.7200 67.8800
Subtotal (Total Children Is Unduplicated) 348 2328.750000 119846.7800 51.4640
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Total 5055.500000 233350.2800 46.1577
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Number of Children (Unduplicated) With at Least One Service 566
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Center 53
Flag Claims Units Chgs Paid
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R 1 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 289 251.500000 10736.7500 9.2500
P 2977 2838.500000 117862.5000 117794.0000
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
1907 1964.000000 104695.5300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5174 5055.500000 233350.2800 117803.2500