CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 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 310 1082.750000 39997.0000 36.9402
Subtotal (Total Children Is Unduplicated) 310 1082.750000 39997.0000 36.9402
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 8.2800 8.2800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.0800 21.0800
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 43 83.500000 6262.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 30.000000 2250.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 24.500000 1837.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 45 86.000000 4712.0000 54.7907
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.000000 291.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.000000 194.0000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 8 8.000000 400.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 7.000000 339.5000 48.5000
Subtotal (Total Children Is Unduplicated) 85 274.000000 17894.6100 65.3088
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 9.000000 225.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 87 411.250000 20550.0000 49.9696
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 9 69.000000 3450.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 141.500000 9605.0200 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 2 3.000000 162.9600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 45 333.250000 22417.3700 67.2689
PHY-97110HM-PT SESSION BY PT ASST 1 1.500000 81.4800 54.3200
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 4 19.000000 950.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 78 378.643040 25702.2897 67.8800
Subtotal (Total Children Is Unduplicated) 175 1366.143040 83144.1197 60.8605
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Total 2722.893040 141035.7297 51.7963
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Number of Children (Unduplicated) With at Least One Service 316
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Center 52
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 504 396.000000 20545.4400 0.0000
P 1838 1255.000000 52714.7700 52714.7700
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
425 1071.893040 67775.5197 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2767 2722.893040 141035.7297 52714.7700