CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 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 300 764.750000 28295.7500 37.0000
Subtotal (Total Children Is Unduplicated) 300 764.750000 28295.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 12.000000 666.0000 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 55.000000 3052.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 56.000000 4200.0000 75.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 46 146.500000 9654.5000 65.9010
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 7 11.000000 275.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 257 783.500000 39175.0000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 2.000000 100.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 15.000000 1018.2000 67.8800
PHY-97110-PT SESSION BY LICENSED PT 21 59.000000 4004.9200 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 5 6.000000 300.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 11 21.000000 1425.4800 67.8800
Subtotal (Total Children Is Unduplicated) 279 897.500000 46298.6000 51.5862
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Total 1808.750000 84248.8500 46.5785
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Number of Children (Unduplicated) With at Least One Service 431
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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 2 2.250000 159.2500 0.0000
P 1162 1087.000000 45334.2500 45334.2500
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
700 719.500000 38755.3500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1864 1808.750000 84248.8500 45334.2500