CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 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 238 93.000000 3441.0000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 66 67.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 210 294.250000 10887.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 534 1257.750000 46111.2500 36.6617
TCON-TCON-TRANSITION CONFERENCE 26 27.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 562 1739.000000 60439.5000 34.7553
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Screening, Eval, and Assessment,Class #02
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
EXIT-EXIT-TRANSITION ASSESSMENT 27 49.000000 2450.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 18.000000 1350.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 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 7 13.500000 749.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 63 109.500000 8212.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 45 71.500000 5362.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 35 58.500000 3246.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 45 80.000000 6000.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 138 419.500000 28837.0000 68.7414
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 5.000000 649.0400 129.8080
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 20 24.500000 1225.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 8 4.500000 225.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 5 1.500000 37.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 7 4.000000 200.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.250000 6.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.500000 25.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 20 17.500000 875.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 0.750000 18.7500 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 27.000000 675.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 56 304.750000 12762.5000 41.8786
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 20.000000 1000.0000 50.0000
INTR-INTR-INTERPRETER 7 20.250000 913.7500 45.1235
OCCT-97530-OT SESSION BY LICENSED OT 30 153.250000 10300.7900 67.2156
PHY-97110-PT SESSION BY LICENSED PT 16 57.000000 3800.1900 66.6700
SENS-FM-FM RECEIVER HEARING AID 1 2.000000 3275.0000 1637.5000
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.000000 456.0000 228.0000
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 54 306.000000 20747.2800 67.8016
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 338 74360.00000 37180.0000 0.5000
Subtotal (Total Children Is Unduplicated) 349 75312.75000 94408.0500 1.2535
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Total 77471.250000 183684.5500 2.3710
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Number of Children (Unduplicated) With at Least One Service 652
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Center 02
Flag Claims Units Chgs Paid
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R 3 3.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1085 865.250000 31746.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 2 3.750000 138.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 779 36414.250000 49030.0300 49030.0300
2199 40185.000000 102658.7700 3275.0000
Other 0 0.000000 0.0000 0.0000
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Total 4068 77471.250000 183684.5500 52305.0300