CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2012 ending 09/30/2012 Date of Report:11/16/2012 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 522 458.250000 16816.5000 36.6972
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 279 309.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 422 565.250000 20877.2500 36.9345
TCM-T1017TL-TARGETED CASE MANAGEMENT 746 2985.750000 109773.7500 36.7659
TCON-TCON-TRANSITION CONFERENCE 45 45.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 780 4363.250000 147467.5000 33.7976
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.3400 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 65.1900 21.7300
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 25.2600 25.2600
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 27.2800 27.2800
EXIT-EXIT-TRANSITION ASSESSMENT 64 121.750000 6087.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 28 54.000000 4050.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 15.000000 1125.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 37 71.000000 3940.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 13.500000 1012.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.500000 562.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 19.500000 1462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 120 231.000000 12820.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 103 204.000000 15300.0000 75.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 13.000000 630.5000 48.5000
Subtotal (Total Children Is Unduplicated) 237 757.250000 47167.0700 62.2873
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 3.000000 671.1800 223.7267
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 90 121.000000 6050.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 20 15.500000 387.5000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 150 311.750000 15587.5000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 22 13.500000 337.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 8 80.000000 4000.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 38 62.000000 3100.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 7 3.250000 81.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 51 89.250000 4462.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 11 8.250000 206.2500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 17 45.000000 3299.4000 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 15 24.000000 600.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 436 2996.750000 149812.5000 49.9917
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 6 11.750000 587.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 28.000000 1900.6400 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 2 45.000000 2444.4000 54.3200
PHY-97110-PT SESSION BY LICENSED PT 22 118.000000 8009.8400 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 54.3200 54.3200
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 12 40.000000 2000.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 201.248700 13660.7629 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 558 162914.0000 81378.0000 0.4995
Subtotal (Total Children Is Unduplicated) 565 167133.2487 298681.0429 1.7871
-----------------------------------------------------------------------------------------------------------------------
Total 172253.748700 493315.6129 2.8639
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 801
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 289 251.500000 10736.7500 9.2500
P 2982 2839.160000 117895.5000 117827.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 751 36926.053624 35357.0300 35357.0300
T 2364 52579.250000 66905.0900 66811.5900
6732 79616.785076 260382.4929 110.5000
Other 39 39.500000 1983.2500 0.0000
---------------------------------------------------------
Total 13158 172253.748700 493315.6129 220115.3700