CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2011 ending 09/30/2011 Date of Report:12/01/2011 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 501 1796.000000 66239.2500 36.8815
Subtotal (Total Children Is Unduplicated) 501 1796.000000 66239.2500 36.8815
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Screening, Eval, and Assessment,Class #02
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.0800 21.0800
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 15 30.000000 2250.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 19 36.500000 2025.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 32.000000 2400.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 13.500000 1012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 55 108.500000 5827.5000 53.7097
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 60 142.500000 10687.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 145.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.000000 388.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 25 25.000000 1212.5000 48.5000
Subtotal (Total Children Is Unduplicated) 122 409.500000 26682.8300 65.1595
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 12 20.000000 500.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 353 2278.250000 113899.5000 49.9943
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 6 19.000000 950.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 153.000000 10385.6400 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 1 3.000000 162.9600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 47 360.000000 24436.8000 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 9 15.000000 750.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 40 252.500000 17085.0200 67.6634
Subtotal (Total Children Is Unduplicated) 377 3100.750000 168169.9200 54.2352
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Total 5306.250000 261092.0000 49.2046
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Number of Children (Unduplicated) With at Least One Service 545
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Center 53
Flag Claims Units Chgs Paid
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R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 86 77.250000 3456.7100 203.5000
P 2107 1807.750000 72331.5000 72331.5000
D 268 230.750000 12312.4800 0.0000
S 1 0.250000 9.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3145 3188.750000 172926.5600 0.0000
Other 1 0.500000 18.5000 0.0000
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Total 5609 5306.250000 261092.0000 72535.0000