CMS/EIP Fiscal Report Center: 06
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 775 543.500000 20106.2500 36.9940
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 7 7.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 665 631.750000 23374.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1489 4879.750000 180513.7500 36.9924
Subtotal (Total Children Is Unduplicated) 1510 6062.000000 223994.7500 36.9506
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 105 107.000000 885.9600 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 103 105.000000 1089.9000 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 104 106.000000 2234.4800 21.0800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.000000 108.7600 27.1900
EXIT-EXIT-TRANSITION ASSESSMENT 4 6.000000 300.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 12.500000 937.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 9.500000 712.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 232 358.000000 26850.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 199 305.500000 22912.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 42 70.000000 5250.0000 75.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 7 7.000000 400.8900 57.2700
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.000000 174.0000 43.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 4.000000 194.0000 48.5000
Subtotal (Total Children Is Unduplicated) 278 1101.500000 62248.9900 56.5129
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 3.000000 303.6200 101.2067
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 38 33.000000 1630.0000 49.3939
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 10 6.750000 156.2500 23.1481
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 3 3.000000 150.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 9 7.250000 356.2500 49.1379
CONPF-CONPF-CONSULT, PT, FACE TO FACE 9 6.500000 325.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 2.500000 62.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 10 11.000000 550.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 3.000000 75.0000 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 4 35.000000 1750.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 307 1861.750000 92649.0600 49.7645
INTR-INTR-INTERPRETER 59 187.750000 11560.9400 61.5762
OCCT-97530-OT SESSION BY LICENSED OT 79 385.000000 26451.8000 68.7060
OCCT-97530HM-OT SESSION BY OT ASST 13 58.750000 3474.7000 59.1438
PHY-97110-PT SESSION BY LICENSED PT 114 578.500000 39466.4400 68.2220
PHY-97110HM-PT SESSION BY PT ASST 6 7.500000 666.0700 88.8093
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 271 1435.000000 95891.7900 66.8235
SPL-92508-GROUP SPL SESSION PER CHILD 7 89.000000 1174.8000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 2 105.000000 77.0000 0.7333
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 588 99731.00000 50022.7500 0.5016
Subtotal (Total Children Is Unduplicated) 690 104550.2500 326793.9700 3.1257
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Total 111713.750000 613037.7100 5.4876
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Number of Children (Unduplicated) With at Least One Service 1558
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Center 06
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 2717 1974.500000 73056.5000 0.0000
P 4397 46144.500000 114780.1200 81526.3700
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 0 0.000000 0.0000 0.0000
12843 63594.750000 425201.0900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 19957 111713.750000 613037.7100 81526.3700