CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2012 ending 06/30/2012 Date of Report:08/16/2012 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 470 559.000000 20683.0000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 319 372.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 510 803.500000 29729.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 771 2959.000000 108956.7500 36.8222
TCON-TCON-TRANSITION CONFERENCE 67 68.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 807 4761.500000 159369.2500 33.4704
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 5 5.000000 242.5000 48.5000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 10.3800 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.0800 21.0800
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 30.3100 30.3100
BEHV-BEHV-BEHAVIORAL ASSESSMENT 3 3.000000 375.0000 125.0000
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.000000 125.0000 125.0000
EXIT-EXIT-TRANSITION ASSESSMENT 63 124.750000 6237.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 28 55.000000 4087.5000 74.3182
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 14.000000 1050.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 32 62.000000 3441.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 39.500000 2962.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 33.000000 2475.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 23.000000 1725.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 147 290.500000 16122.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 143 279.500000 20886.5000 74.7281
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 145.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 8.000000 388.0000 48.5000
Subtotal (Total Children Is Unduplicated) 270 949.250000 60674.0200 63.9179
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 8 12.000000 3563.0400 296.9200
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 93 142.500000 7125.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 36 35.250000 881.2500 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 152 234.500000 11725.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 29 13.000000 325.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 37 54.500000 2656.2500 48.7385
CONOP-CONOP-CONSULT, OT, PHONE 4 2.000000 50.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 44 59.500000 2975.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 7 2.250000 56.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 52 75.750000 3787.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 4 2.000000 50.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 11 43.000000 3116.1000 72.4674
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 8 21.000000 525.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 6 56.000000 2800.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 454 2894.750000 144775.0000 50.0130
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 8 16.500000 825.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 20 159.000000 10792.9200 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 3 56.000000 3041.9200 54.3200
PHY-97110-PT SESSION BY LICENSED PT 45 380.500000 25828.3400 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 15 31.500000 1575.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 43 313.884970 21306.5129 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.000000 26.4000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 606 168137.0000 84061.0000 0.5000
Subtotal (Total Children Is Unduplicated) 613 172744.3850 331867.4829 1.9211
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Total 178455.134970 551910.7529 3.0927
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Number of Children (Unduplicated) With at Least One Service 842
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Center 53
Flag Claims Units Chgs Paid
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R 2 2.500000 133.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 755 642.250000 23834.5000 37.0000
P 3427 48279.581010 146191.5050 146154.0100
D 7 6.000000 298.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1534 52286.193135 54263.4200 54263.4200
8310 77195.610825 324765.0779 168.0000
Other 39 43.000000 2425.0000 0.0000
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Total 14074 178455.134970 551910.7529 200622.4300