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
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 402 264.500000 9777.2500 36.9650
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 333 386.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 442 428.250000 15817.5000 36.9352
TCM-T1017TL-TARGETED CASE MANAGEMENT 763 2649.500000 97698.5000 36.8743
TCON-TCON-TRANSITION CONFERENCE 47 48.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 786 3776.250000 123293.2500 32.6497
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.000000 97.0000 48.5000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.0800 21.0800
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 2 2.000000 200.0000 100.0000
EXIT-EXIT-TRANSITION ASSESSMENT 54 97.250000 4862.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 23 46.000000 3450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 16.000000 1200.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 27 52.500000 2913.7500 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 35 69.500000 5212.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 33.500000 2512.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 112 221.500000 12099.0000 54.6230
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 121 283.000000 21150.0000 74.7350
NUTR-97802-NUTRITIONAL EVAL, INITIAL 2 2.000000 100.0000 50.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 11 11.000000 533.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.000000 436.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 39 39.000000 1891.5000 48.5000
Subtotal (Total Children Is Unduplicated) 272 896.750000 57464.3300 64.0807
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 5.000000 827.7200 165.5440
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 146 216.750000 10825.0000 49.9423
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 52 83.500000 2087.5000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 135 351.250000 17550.0000 49.9644
CONIP-CONIP-CONSULT, ITDS, PHONE 35 29.750000 743.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 18 14.750000 737.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 8 6.750000 168.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 36 41.000000 2050.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 8 5.250000 131.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 36 55.250000 2762.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 16 8.250000 206.2500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 6 24.500000 1796.3400 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 19 29.500000 737.5000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 7 35.000000 1750.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 451 2870.000000 143487.0000 49.9955
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 9 45.000000 2250.0000 50.0000
INTR-INTR-INTERPRETER 5 8.250000 412.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 44 336.750000 22858.5900 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 2 5.000000 271.6000 54.3200
PHY-97110-PT SESSION BY LICENSED PT 78 587.499830 39879.4884 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 4.000000 217.2800 54.3200
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 11 20.000000 1000.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 85 587.749990 39841.7893 67.7870
SPL-92508-GROUP SPL SESSION PER CHILD 2 1.000000 13.2000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 608 176557.0000 88065.7500 0.4988
Subtotal (Total Children Is Unduplicated) 615 181928.7498 380671.2577 2.0924
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Total 186601.749820 561428.8377 3.0087
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Number of Children (Unduplicated) With at Least One Service 840
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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 97 87.750000 3934.2100 203.5000
P 2374 2117.622200 85478.8600 85478.8600
D 329 285.500000 14666.4800 0.0000
S 1 0.250000 9.2500 0.0000
H 1245 46003.348700 53206.5998 53206.6000
T 2392 51512.250000 72989.3400 72913.5900
7694 86593.528920 331088.5979 357.5000
Other 1 0.500000 18.5000 0.0000
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Total 14134 186601.749820 561428.8377 212160.0500