CMS/EIP Fiscal Report Center: 03
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 1079 712.500000 26362.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 508 611.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 266 236.000000 8732.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1444 3910.750000 144697.7500 37.0000
TCON-TCON-TRANSITION CONFERENCE 89 89.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 1521 5559.250000 179792.2500 32.3411
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 15.2500 15.2500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 73 73.000000 604.4400 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 12 12.000000 124.5600 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 73 73.000000 1538.8400 21.0800
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.000000 155.2800 51.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 6 6.000000 163.1400 27.1900
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 30.3100 30.3100
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
EXIT-EXIT-TRANSITION ASSESSMENT 53 75.250000 3762.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 8.000000 600.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 15.000000 832.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 112 184.000000 13800.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 102 172.500000 12937.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 61 100.500000 7537.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 184 301.500000 16733.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 19.0800 19.0800
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.000000 122.0400 30.5100
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.000000 251.0000 41.8333
SCREEN-T1023-INTERDISCIPLINARY SCREENING 45 45.000000 2250.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 7.000000 299.5500 42.7929
Subtotal (Total Children Is Unduplicated) 419 1104.250000 62979.2400 57.0335
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 19.000000 664.7900 34.9889
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 164 171.500000 8550.0000 49.8542
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 4 1.750000 43.7500 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 131 251.250000 10087.5000 40.1493
CONIP-CONIP-CONSULT, ITDS, PHONE 10 8.250000 206.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 61 87.000000 4350.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 66 113.250000 5656.2500 49.9448
CONPP-CONPP-CONSULT, PT, PHONE 2 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 130 159.500000 7975.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 5 5.500000 137.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 141 1016.750000 50837.5000 50.0000
INTR-INTR-INTERPRETER 28 361.000000 19260.0000 53.3518
OCCT-97530-OT SESSION BY LICENSED OT 38 224.250000 12531.3100 55.8810
PHY-97110-PT SESSION BY LICENSED PT 41 257.500000 16211.6600 62.9579
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 1.000000 228.0000 228.0000
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 96 624.250000 38443.7300 61.5839
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 593 131152.0000 65510.5000 0.4995
Subtotal (Total Children Is Unduplicated) 633 134456.7500 240761.7400 1.7906
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Total 141120.250000 483533.2300 3.4264
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Number of Children (Unduplicated) With at Least One Service 1553
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Center 03
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 60 32.500000 1458.2500 0.0000
P 6644 49426.500000 184415.2100 184408.9600
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 4652 2566.000000 82347.9200 82347.9200
7486 88936.000000 212748.7000 0.0000
Other 160 159.250000 2563.1500 0.0000
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Total 19002 141120.250000 483533.2300 266756.8800