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
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 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 254 749.750000 27463.2500 36.6299
TCON-TCON-TRANSITION CONFERENCE 67 68.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 725 2552.250000 77875.7500 30.5126
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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 9 19.000000 1387.5000 73.0263
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 12.000000 666.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.672200 425.4150 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 26.000000 1443.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 44.500000 3337.5000 75.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.000000 97.0000 48.5000
Subtotal (Total Children Is Unduplicated) 110 255.922200 15148.1850 59.1906
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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 93 141.500000 7075.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 36 35.250000 881.2500 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 152 233.500000 11675.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 29 13.000000 325.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 36 51.500000 2506.2500 48.6650
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 33.000000 2419.5600 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 8.000000 200.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 6 56.000000 2800.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 105 532.250000 26612.5000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 4.500000 225.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 13.000000 882.4400 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 2 28.000000 1520.9600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 11 59.750000 4055.8300 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 3 6.000000 300.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 22 178.053445 12086.2684 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 606 168137.0000 84061.0000 0.5000
Subtotal (Total Children Is Unduplicated) 612 169683.8034 168107.8484 0.9907
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Total 172491.975645 261131.7834 1.5139
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Number of Children (Unduplicated) With at Least One Service 812
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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 1195 46043.581010 50100.9750 50100.9800
D 6 4.000000 148.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1511 52263.193135 53041.9000 53041.9000
5406 74181.201500 157840.9084 168.0000
Other 0 0.000000 0.0000 0.0000
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Total 8118 172491.975645 261131.7834 103310.8800