CMS/EIP Fiscal Report Center: 07
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 1041 860.250000 31829.2500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 56 58.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 645 909.750000 33660.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1557 4947.750000 183066.7500 37.0000
TCON-TCON-TRANSITION CONFERENCE 17 17.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 1666 6792.750000 248556.7500 36.5915
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 5.000000 41.4000 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 20.7600 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 63.2400 21.0800
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 2.000000 45.9200 22.9600
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 51.7600 51.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 27.1900 27.1900
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 3.000000 90.9300 30.3100
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 6.000000 322.0000 53.6667
EXIT-EXIT-TRANSITION ASSESSMENT 29 43.250000 2162.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 15.500000 1162.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 59 114.500000 8587.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 18.000000 1350.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 112 216.500000 12015.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 175 447.000000 33525.0000 75.0000
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 72.7800 72.7800
NUTR-97802-NUTRITIONAL EVAL, INITIAL 3 2.000000 100.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 2 1.000000 50.0000 50.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.000000 174.0000 43.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 145.5000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 16 16.000000 800.0000 50.0000
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 3 4.000000 60.0000 15.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.000000 145.5000 48.5000
Subtotal (Total Children Is Unduplicated) 286 925.250000 61919.4800 66.9219
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 26 33.000000 1650.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 2 2.000000 50.0000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 20 30.500000 1525.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 13 8.000000 200.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 15 33.500000 1675.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 11 12.250000 612.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.750000 18.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 28 43.750000 2187.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 3 1.250000 31.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 686 4841.000000 241320.8900 49.8494
INTR-INTR-INTERPRETER 2 3.500000 175.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 28 156.250000 9499.6700 60.7979
PHY-97110-PT SESSION BY LICENSED PT 23 93.750000 5078.9600 54.1756
SENS-V5264-EARMOLD 2 3.000000 54.0000 18.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.000000 50.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 88 622.500000 41543.0500 66.7358
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 776 156562.0000 78266.0000 0.4999
Subtotal (Total Children Is Unduplicated) 884 162448.0000 383937.5700 2.3634
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Total 170166.000000 694413.8000 4.0808
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Number of Children (Unduplicated) With at Least One Service 1754
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Center 07
Flag Claims Units Chgs Paid
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R 15 8.750000 323.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 144 86.250000 3191.2500 0.0000
P 7639 156981.250000 351163.6100 351154.3600
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
7952 13089.750000 339735.1900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 15750 170166.000000 694413.8000 351154.3600