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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 567 2061.000000 76025.7500 36.8878
Subtotal (Total Children Is Unduplicated) 567 2061.000000 76025.7500 36.8878
-----------------------------------------------------------------------------------------------------------------------
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 16 32.000000 2400.0000 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 20 38.500000 2136.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 40.000000 3000.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 19.500000 1462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 87 172.000000 9351.7500 54.3706
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 92 212.000000 15900.0000 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) 160 560.500000 36730.5800 65.5318
-----------------------------------------------------------------------------------------------------------------------
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 354 2279.250000 113949.5000 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) 378 3101.750000 168219.9200 54.2339
-----------------------------------------------------------------------------------------------------------------------
Total 5723.250000 280976.2500 49.0938
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 612
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 96 86.750000 3884.2100 203.5000
P 2368 2114.750000 85341.7500 85341.7500
D 273 240.750000 13062.4800 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
3200 3279.250000 178623.0600 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 5940 5723.250000 280976.2500 85545.2500