CMS/EIP Fiscal Report Center: 10
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 4 2.750000 101.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 821 917.500000 33947.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2382 9147.000000 338439.0000 37.0000
Subtotal (Total Children Is Unduplicated) 2382 10067.25000 372488.2500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 20 20.000000 237.2000 11.8600
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 20 20.000000 165.6000 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 19 19.000000 197.2200 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 19 19.000000 400.5200 21.0800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 11 11.000000 299.0900 27.1900
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 2.500000 125.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 30 48.500000 3637.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 19.000000 1425.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 15.000000 1125.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 16.500000 1237.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 39 72.500000 4023.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 253 459.000000 34425.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 127 197.000000 14775.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 103 171.000000 12825.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 350 631.500000 35048.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 156 201.000000 15075.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 17 18.000000 873.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 6.000000 242.5000 40.4167
SPCH-92506-SPEECH EVAL BY LICENSED SLP 14 15.000000 679.0000 45.2667
Subtotal (Total Children Is Unduplicated) 547 1961.500000 126816.1300 64.6526
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 10 49.000000 9467.5900 193.2161
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 130 137.000000 6850.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.500000 12.5000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 17 9.250000 462.5000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 7 2.500000 62.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 23 18.250000 912.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 11 5.250000 131.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 4.250000 212.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 7 3.000000 75.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 35 26.500000 1325.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 16 6.000000 150.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 21 105.000000 2625.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 457 4708.250000 235412.5000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 8 28.500000 1425.0000 50.0000
INTR-INTR-INTERPRETER 2 12.000000 600.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 254 1184.000000 79487.4800 67.1347
OCCT-97530HM-OT SESSION BY OT ASST 31 106.500000 5656.5400 53.1131
PHY-97110-PT SESSION BY LICENSED PT 430 1722.500000 115027.8100 66.7796
PHY-97110HM-PT SESSION BY PT ASST 5 9.500000 516.0400 54.3200
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 3.000000 150.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 441 2165.250000 146094.7300 67.4725
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 33 95.000000 5160.4000 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.2000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 690 178230.0000 89115.0000 0.5000
Subtotal (Total Children Is Unduplicated) 1032 188632.0000 700945.0400 3.7159
-----------------------------------------------------------------------------------------------------------------------
Total 200660.750000 1200249.4200 5.9815
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2410
-----------------------------------------------------------------------------------------------------------------------
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 47 24.250000 1011.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1575 1648.500000 92813.5000 6669.2500
P 13117 188414.250000 574241.3500 566755.1000
D 14 14.000000 518.0000 18740.2500
S 91 77.250000 2858.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
8510 10482.500000 528807.0700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23354 200660.750000 1200249.4200 592164.6000