CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2012 ending 03/31/2012 Date of Report:05/16/2012 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 539 551.750000 20257.5000 36.7150
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 343 380.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 489 549.750000 20266.7500 36.8654
TCM-T1017TL-TARGETED CASE MANAGEMENT 767 3181.500000 117003.2500 36.7761
TCON-TCON-TRANSITION CONFERENCE 51 52.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 808 4715.000000 157527.5000 33.4099
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 4 4.000000 194.0000 48.5000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 20.7600 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 3.000000 63.2400 21.0800
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 30.3100 30.3100
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 3 3.000000 300.0000 100.0000
EXIT-EXIT-TRANSITION ASSESSMENT 71 132.000000 6600.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 21 48.000000 3600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 13 26.000000 1950.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 35 70.000000 3885.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 64.500000 4837.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 18.000000 1275.0000 70.8333
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 12.000000 900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 163 322.000000 17871.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 154 306.000000 22950.0001 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 97.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 7.000000 339.5000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.000000 50.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 11 11.000000 533.5000 48.5000
Subtotal (Total Children Is Unduplicated) 302 1038.500000 65946.8101 63.5020
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 7.000000 2054.5300 293.5043
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 112 185.000000 9250.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 41 38.000000 950.0000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 156 368.000000 18387.5000 49.9660
CONIP-CONIP-CONSULT, ITDS, PHONE 34 18.500000 462.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 21 23.000000 1150.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 1.500000 37.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 48 49.000000 2450.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 5 2.750000 68.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 45 64.750000 3237.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 7 6.750000 168.7500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 8 31.750000 2327.9100 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 18 34.000000 850.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 10 82.000000 4100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 456 3002.500000 150125.0000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 5 9.000000 450.0000 50.0000
INTR-INTR-INTERPRETER 3 5.500000 275.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 202.999980 13779.6387 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 5 82.000000 4454.2400 54.3200
PHY-97110-PT SESSION BY LICENSED PT 57 460.250000 31241.7700 67.8800
PHY-97110HM-PT SESSION BY PT ASST 11 42.000000 2281.4400 54.3200
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 11 18.000000 900.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 69 397.250000 26965.3300 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.2000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 1 60.000000 6000.0000 100.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 630 180876.0000 90317.5000 0.4993
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 2 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 635 186071.5000 372448.0587 2.0016
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Total 191824.999980 595922.3688 3.1066
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Number of Children (Unduplicated) With at Least One Service 844
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Center 53
Flag Claims Units Chgs Paid
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R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 678 785.000000 31469.5000 0.0000
P 1841 1739.449000 73630.9500 73556.9500
D 272 251.250000 10604.0000 0.0000
S 514 430.500000 17134.7500 0.0000
H 1223 45081.000000 48725.2400 48725.2400
T 1269 46965.500000 50925.8200 50925.8200
9444 96566.800980 363163.6088 272.0200
Other 5 5.000000 250.0000 0.0000
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Total 15247 191824.999980 595922.3688 173480.0300