CMS/EIP Fiscal Report Center: 53
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 486 440.750000 16243.0000 36.8531
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 297 336.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 489 591.500000 21783.7500 36.8280
TCM-T1017TL-TARGETED CASE MANAGEMENT 783 2854.750000 104673.0000 36.6663
TCON-TCON-TRANSITION CONFERENCE 74 75.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 819 4298.000000 142699.7500 33.2014
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.000000 97.0000 48.5000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 6.000000 62.2800 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 6.000000 126.4800 21.0800
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 30.3100 30.3100
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 12 12.000000 1350.0000 112.5000
EXIT-EXIT-TRANSITION ASSESSMENT 59 108.000000 5400.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 17 33.000000 2475.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 11 21.000000 1537.5000 73.2143
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 25 49.000000 2711.2500 55.3316
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 52.000000 3900.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 30.000000 2250.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 136 271.500000 15057.2500 55.4595
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 136 307.999800 23062.4850 74.8782
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 6.999990 339.4995 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 9.000000 436.5000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.000000 50.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 21 22.000000 1067.0000 48.5000
Subtotal (Total Children Is Unduplicated) 291 938.499790 59952.5545 63.8813
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 12.000000 2813.5500 234.4625
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 94 140.500000 7025.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 32 29.000000 725.0000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 141 298.750000 14931.2500 49.9791
CONIP-CONIP-CONSULT, ITDS, PHONE 34 19.500000 487.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 5 6.000000 300.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 34 48.000000 2400.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 0.750000 18.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 35 52.250000 2612.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 11 37.500000 937.5000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 5 21.000000 1539.7200 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 15 34.000000 850.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 9 60.000000 3000.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 445 2976.750000 148837.5000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 8 24.000000 1200.0000 50.0000
INTR-INTR-INTERPRETER 3 5.500000 295.0000 53.6364
OCCT-97530-OT SESSION BY LICENSED OT 42 349.249900 23707.0830 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 7 85.000000 4617.2000 54.3200
PHY-97110-PT SESSION BY LICENSED PT 61 477.499970 32399.1379 67.8516
PHY-97110HM-PT SESSION BY PT ASST 2 11.000000 597.5200 54.3200
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 14 25.000000 1250.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 78 485.000000 32921.8000 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 2 4.000000 52.8000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 624 176738.0000 88281.5000 0.4995
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 636 181944.2499 371936.3109 2.0442
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Total 187180.749660 574588.6154 3.0697
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Number of Children (Unduplicated) With at Least One Service 876
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Center 53
Flag Claims Units Chgs Paid
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R 8 6.000000 222.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 60 48.000000 1928.0000 9.2500
P 4716 52063.250000 159576.7300 159711.1800
D 231 252.500000 14087.9000 0.0000
S 0 0.000000 0.0000 0.0000
H 1257 49529.512670 53249.1400 53249.1400
T 918 694.500000 20840.2500 20840.2500
7274 84586.986990 324684.5954 200.0000
Other 0 0.000000 0.0000 0.0000
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Total 14464 187180.749660 574588.6154 234009.8200