CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 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 422 1185.250000 43678.5000 36.8517
Subtotal (Total Children Is Unduplicated) 422 1185.250000 43678.5000 36.8517
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 17.4400 8.7200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 43.7100 21.8550
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 31.5200 31.5200
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.000000 125.0000 125.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 16.000000 1200.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 21.000000 1129.5000 53.7857
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 36.000000 2700.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 27.500000 2062.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 77 152.000000 8436.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 64 157.500000 11812.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.000000 291.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 13 13.000000 630.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 16 17.000000 824.5000 48.5000
Subtotal (Total Children Is Unduplicated) 112 455.000000 29529.1700 64.8993
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 9.000000 660.7800 73.4200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 16 37.000000 925.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 292 1827.250000 91264.5000 49.9464
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 3.000000 150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 71.000000 4819.4800 67.8800
PHY-97110-PT SESSION BY LICENSED PT 30 199.000000 13508.1200 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.000000 50.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 42 199.000000 13508.1200 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.2000 13.2000
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 324 2348.250000 124949.2000 53.2095
-----------------------------------------------------------------------------------------------------------------------
Total 3988.500000 198156.8700 49.6821
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 505
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 80 83.250000 3321.2500 311.0000
U 0 0.000000 0.0000 0.0000
B 1139 1052.500000 43377.0000 0.0000
P 533 589.750000 28981.5000 28194.0000
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
2363 2263.000000 122477.1200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4115 3988.500000 198156.8700 28505.0000