CMS/EIP Fiscal Report Center: 52
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 403 255.500000 9453.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 67 71.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 284 214.250000 7927.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 593 2082.500000 76950.7500 36.9511
TCON-TCON-TRANSITION CONFERENCE 1 1.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 609 2624.250000 94331.5000 35.9461
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 8.2800 8.2800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.0800 21.0800
EXIT-EXIT-TRANSITION ASSESSMENT 4 4.000000 200.0000 50.0000
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 6 12.000000 422.0000 35.1667
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 19.000000 1425.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 27.000000 1498.5000 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 19 33.500000 1088.5000 32.4925
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 108 205.500000 15412.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 33 65.500000 4912.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 35 64.000000 4800.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 114 215.500000 11899.2500 55.2169
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 19 20.000000 970.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.000000 436.5000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 20 20.000000 1000.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 38 39.000000 1891.5000 48.5000
Subtotal (Total Children Is Unduplicated) 235 749.000000 46960.6100 62.6977
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.000000 2874.7200 1437.3600
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 58 66.000000 3300.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 29 30.000000 1500.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 9 5.250000 131.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 9 8.000000 400.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 6 2.250000 56.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 12 11.000000 550.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 6 3.750000 93.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 24 28.000000 1400.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.500000 12.5000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 24.000000 600.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 200.000000 9415.0000 47.0750
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 10 84.500000 4225.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 123 648.000000 32419.6800 50.0304
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 11 77.000000 3850.0000 50.0000
INTR-INTR-INTERPRETER 11 108.000000 1428.7500 13.2292
OCCT-97530-OT SESSION BY LICENSED OT 58 337.250005 22872.1904 67.8197
OCCT-97530HM-OT SESSION BY OT ASST 3 8.250000 448.1400 54.3200
PHY-97110-PT SESSION BY LICENSED PT 97 723.250000 48890.5700 67.5984
PHY-97110HM-PT SESSION BY PT ASST 1 1.500000 81.4800 54.3200
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 5 28.000000 1400.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 207 1122.149999 76117.0301 67.8314
SPL-92508-GROUP SPL SESSION PER CHILD 2 26.000000 343.2000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 413 97654.00000 48911.5000 0.5009
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 9 27.000000 1350.0000 50.0000
Subtotal (Total Children Is Unduplicated) 445 101225.6500 262671.0105 2.5949
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Total 104598.900004 403963.1205 3.8620
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Number of Children (Unduplicated) With at Least One Service 618
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Center 52
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 564 458.750000 24022.6900 0.0000
P 2440 20046.050212 82396.0500 82396.0500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 90 166.250000 10839.6400 0.0000
T 0 0.000000 0.0000 0.0000
5301 83786.599792 281001.7505 0.0000
Other 42 141.250000 5702.9900 0.0000
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Total 8437 104598.900004 403963.1205 82396.0500