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
Payclass Filters:GR
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 674 1700.500000 62918.5000 37.0000
TCON-TCON-TRANSITION CONFERENCE 89 89.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 1343 3349.000000 98013.0000 29.2663
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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) 6 6.000000 49.6800 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 20.7600 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.000000 105.4000 21.0800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 81.5700 27.1900
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 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 48.000000 3600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 21 37.000000 2775.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 20.000000 1500.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 115 193.500000 10739.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 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 5 5.000000 202.5000 40.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 32 32.000000 1600.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 7.000000 299.5500 42.7929
Subtotal (Total Children Is Unduplicated) 244 459.250000 26200.0800 57.0497
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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 136 997.000000 49850.0000 50.0000
INTR-INTR-INTERPRETER 28 361.000000 19260.0000 53.3518
OCCT-97530-OT SESSION BY LICENSED OT 35 216.500000 12005.2400 55.4515
PHY-97110-PT SESSION BY LICENSED PT 38 234.750000 14667.3900 62.4809
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 95 616.250000 37900.6900 61.5021
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 592 131112.0000 65490.5000 0.4995
Subtotal (Total Children Is Unduplicated) 630 134358.5000 237140.8600 1.7650
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Total 138166.750000 361353.9400 2.6153
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Number of Children (Unduplicated) With at Least One Service 1409
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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 0 0.000000 0.0000 0.0000
P 2691 46936.250000 83323.2100 83323.2100
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
7322 88660.500000 195599.0700 0.0000
Other 4 4.000000 83.7400 0.0000
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Total 14669 138166.750000 361353.9400 165671.1300