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
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 4 2.750000 101.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 821 917.500000 33947.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 925 3356.000000 124172.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1438 4276.250000 158221.2500 37.0000
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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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 49.500000 3712.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 17.000000 1275.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 22.000000 1650.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 68.000000 3774.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 21.500000 1612.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.000000 291.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 61.0000 30.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 7.000000 319.5000 45.6429
Subtotal (Total Children Is Unduplicated) 82 294.000000 14778.1300 50.2657
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 10 41.000000 8551.7700 208.5798
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 184 2034.250000 101712.5000 50.0000
INTR-INTR-INTERPRETER 2 12.000000 600.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 101 507.000000 33691.1200 66.4519
OCCT-97530HM-OT SESSION BY OT ASST 13 56.000000 3013.6600 53.8154
PHY-97110-PT SESSION BY LICENSED PT 146 620.750000 40810.7800 65.7443
PHY-97110HM-PT SESSION BY PT ASST 1 1.500000 81.4800 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 212 1105.500000 74249.8200 67.1640
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 19 62.000000 3367.8400 54.3200
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 690 178210.0000 89105.0000 0.5000
Subtotal (Total Children Is Unduplicated) 821 182967.5000 368002.7200 2.0113
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Total 187537.750000 541002.1000 2.8848
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Number of Children (Unduplicated) With at Least One Service 1729
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Center 10
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 4729 183071.500000 369973.8500 369973.8500
D 14 14.000000 518.0000 18740.2500
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6033 4452.250000 170510.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 10776 187537.750000 541002.1000 388714.1000