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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.250000 9.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 8 12.000000 444.0000 37.0000
Subtotal (Total Children Is Unduplicated) 9 12.250000 453.2500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 26.500000 1470.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 20.000000 1500.0000 75.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.000000 145.5000 48.5000
Subtotal (Total Children Is Unduplicated) 24 73.500000 4721.2500 64.2347
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 60 353.328000 17666.4000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 1.000000 50.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 9.946376 675.1600 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 1 4.000000 217.2800 54.3200
PHY-97110-PT SESSION BY LICENSED PT 1 7.000000 475.1600 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 5.000000 250.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 36.662100 2488.6239 67.8800
Subtotal (Total Children Is Unduplicated) 73 418.936476 21897.6239 52.2696
-----------------------------------------------------------------------------------------------------------------------
Total 504.686476 27072.1239 53.6415
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 88
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 5 0.660000 33.0000 33.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 2.000000 100.0000 100.0000
T 1 1.000000 50.0000 50.0000
463 470.526476 25355.8739 0.0000
Other 30 30.500000 1533.2500 0.0000
---------------------------------------------------------
Total 501 504.686476 27072.1239 183.0000