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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 360 1266.250000 46786.5000 36.9489
Subtotal (Total Children Is Unduplicated) 360 1266.250000 46786.5000 36.9489
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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 7 13.000000 975.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 11.000000 610.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 120.500000 9037.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 38.000000 2850.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 35.000000 2625.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 65 123.500000 6793.2500 55.0061
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) 114 379.500000 25007.6100 65.8962
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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 3011.893040 154938.2297 51.4421
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Number of Children (Unduplicated) With at Least One Service 366
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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 564 458.750000 24022.6900 0.0000
P 2050 1468.750000 62202.5200 62202.5200
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
433 1084.393040 68713.0197 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3047 3011.893040 154938.2297 62202.5200