CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 Page: 1
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 308 753.50 27879.50 37.00
Subtotal (Total Children Is Unduplicated) 308 753.50 27879.50 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 8.00 444.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 41 79.79 5984.27 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 26 47.29 3546.77 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 81 156.00 8658.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 35 63.50 4762.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 9 11.00 533.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.00 436.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 9.00 436.50 48.50
Subtotal (Total Children Is Unduplicated) 114 393.08 25305.96 64.38
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 9 14.00 350.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 332 2026.50 101325.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 5 8.00 400.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 17 79.50 5396.46 67.88
PHY-97110-PT SESSION BY LICENSED PT 21 126.75 8603.79 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 7 13.00 650.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 20 108.00 7331.04 67.88
Subtotal (Total Children Is Unduplicated) 350 2375.75 124056.29 52.22
----------------------------------------------------------------------------------------------------------------
Total 3522.33 177241.75 50.32
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 472
----------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 18 19.75 1016.50 0.00
U 0 0.00 0.00 0.00
B 537 468.25 18844.25 0.00
P 1070 1115.58 55455.29 55399.79
D 4 6.00 359.50 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2036 1912.75 101566.21 800.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 3665 3522.33 177241.75 56199.79