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
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 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 254 732.250000 26982.2500 36.8484
TCON-TCON-TRANSITION CONFERENCE 74 75.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 727 2175.500000 65009.0000 29.8823
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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) 4 5.000000 51.9000 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 5.000000 105.4000 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 58 106.500000 5325.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 23 46.000000 2553.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 45.666600 3424.9950 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 3.356280 162.7796 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 97.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.000000 291.0000 48.5000
Subtotal (Total Children Is Unduplicated) 118 262.522880 15432.3846 58.7849
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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 94 139.500000 6975.0000 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 6 16.000000 400.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 9 60.000000 3000.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 98 618.000000 30900.0000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 4.000000 200.0000 50.0000
INTR-INTR-INTERPRETER 3 5.500000 295.0000 53.6364
OCCT-97530-OT SESSION BY LICENSED OT 14 86.988330 5904.7678 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 6 55.000000 2987.6000 54.3200
PHY-97110-PT SESSION BY LICENSED PT 20 124.573210 8442.4694 67.7711
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 2.000000 100.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 28 182.000000 12354.1600 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 623 176433.0000 88129.0000 0.4995
Subtotal (Total Children Is Unduplicated) 631 178253.3115 186489.7672 1.0462
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Total 180691.334420 266931.1518 1.4773
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Number of Children (Unduplicated) With at Least One Service 847
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Center 53
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 2288 49906.250000 72554.4400 72688.8900
D 54 50.500000 2185.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 1239 49511.512670 52206.1000 52206.1000
T 918 694.500000 20840.2500 20840.2500
3660 80528.571750 119144.8618 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 8159 180691.334420 266931.1518 145735.2400