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:Program Patients
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 502 1502.250000 55407.5000 36.8830
Subtotal (Total Children Is Unduplicated) 502 1502.250000 55407.5000 36.8830
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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 5 8.500000 637.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 26.500000 1434.7500 54.1415
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 32 62.500000 4687.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 45.000000 3375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 130 255.500000 14124.7500 55.2828
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 112 281.500000 21037.5000 74.7336
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.000000 339.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 14 14.000000 679.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 16 17.000000 824.5000 48.5000
Subtotal (Total Children Is Unduplicated) 176 739.500000 48557.6700 65.6628
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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 301 1859.250000 92864.5000 49.9473
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 4 15.000000 750.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 73.000000 4955.2400 67.8800
PHY-97110-PT SESSION BY LICENSED PT 31 204.000000 13847.5200 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) 333 2399.250000 127624.3600 53.1934
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Total 4641.000000 231589.5300 49.9008
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Number of Children (Unduplicated) With at Least One Service 586
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Center 53
Flag Claims Units Chgs Paid
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R 97 107.500000 4255.5000 311.0000
U 0 0.000000 0.0000 0.0000
B 1346 1296.000000 54015.7500 0.0000
P 699 834.000000 41830.5000 40180.5000
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
2459 2403.500000 131487.7800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4601 4641.000000 231589.5300 40491.5000