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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 7.000000 259.0000 37.0000
Subtotal (Total Children Is Unduplicated) 4 8.000000 259.0000 32.3750
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
Subtotal (Total Children Is Unduplicated) 9 28.000000 1788.0000 63.8571
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 24 71.875000 3593.7500 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 2.000000 135.7600 67.8800
PHY-97110-PT SESSION BY LICENSED PT 2 4.000000 271.5200 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 4.811200 326.5843 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 82.000000 41.0000 0.5000
Subtotal (Total Children Is Unduplicated) 29 164.686200 4368.6143 26.5269
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Total 200.686200 6415.6143 31.9684
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Number of Children (Unduplicated) With at Least One Service 40
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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 7 5.264000 263.2000 403.5500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.000000 50.0000 50.0000
T 0 0.000000 0.0000 0.0000
90 181.422200 5452.4143 0.0000
Other 13 13.000000 650.0000 0.0000
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Total 111 200.686200 6415.6143 453.5500