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
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 539 551.500000 20248.2500 36.7149
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 343 379.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 489 549.750000 20266.7500 36.8654
TCM-T1017TL-TARGETED CASE MANAGEMENT 251 650.750000 23902.0000 36.7299
TCON-TCON-TRANSITION CONFERENCE 51 51.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 738 2182.000000 64417.0000 29.5220
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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 5 11.500000 862.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 12.000000 666.0000 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 18 36.000000 1998.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 39.805870 2985.4403 75.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 97.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.000000 97.0000 48.5000
Subtotal (Total Children Is Unduplicated) 123 266.305870 15264.2503 57.3185
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 6.850000 1967.7900 287.2686
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 20 22.000000 1100.0000 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 8 18.000000 450.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 10 82.000000 4100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 106 610.051000 30502.5500 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 2.000000 100.0000 50.0000
INTR-INTR-INTERPRETER 3 5.500000 275.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 8 45.026657 3056.4095 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 4 38.000000 2064.1600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 17 87.500000 5939.5000 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 3.000000 150.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 22 154.636270 10496.7100 67.8800
TRAN-TRAN-FAMILY TRANSPORTATION 1 60.000000 6000.0000 100.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 630 180762.0000 90260.5000 0.4993
Subtotal (Total Children Is Unduplicated) 633 182662.5639 193803.0295 1.0610
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Total 185110.869797 273484.2798 1.4774
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Number of Children (Unduplicated) With at Least One Service 816
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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 0 0.000000 0.0000 0.0000
D 46 42.500000 1953.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 1209 45067.000000 47953.7200 47953.7200
T 1254 46950.500000 50086.4200 50086.4200
6152 93050.869797 173490.6398 0.5000
Other 0 0.000000 0.0000 0.0000
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Total 8661 185110.869797 273484.2798 98040.6400