CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Payclass Filters:TPIN
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 10 24.250000 897.2500 37.0000
Subtotal (Total Children Is Unduplicated) 10 24.250000 897.2500 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 10.3800 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.0800 21.0800
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.500000 75.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 14.000000 1050.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 24 48.500000 2691.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 50.833200 3774.9900 74.2623
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 0.643710 31.2199 48.4999
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 5.000000 242.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 10 10.000000 485.0000 48.5000
Subtotal (Total Children Is Unduplicated) 44 140.476910 8981.9199 63.9388
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 18 73.500000 3675.0000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 3.000000 150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 51.511570 3496.6052 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 4 17.000000 923.4400 54.3200
PHY-97110-PT SESSION BY LICENSED PT 17 95.926760 6511.5085 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.000000 50.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 11 68.000000 4615.8400 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 2 4.000000 52.8000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 15.000000 7.5000 0.5000
Subtotal (Total Children Is Unduplicated) 51 329.938330 19532.6937 59.2010
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Total 494.665240 29411.8636 59.4581
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Number of Children (Unduplicated) With at Least One Service 91
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Center 53
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 0 0.000000 0.0000 0.0000
P 25 24.750000 1480.5400 1480.5400
D 11 7.250000 330.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 18 18.000000 1043.0400 1043.0400
T 0 0.000000 0.0000 0.0000
374 444.665240 26558.2836 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 428 494.665240 29411.8636 2523.5800