CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2012 ending 09/30/2012 Date of Report:11/15/2012 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 522 458.000000 16807.2500 36.6971
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 230 714.500000 26325.5000 36.8446
TCON-TCON-TRANSITION CONFERENCE 45 45.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 702 2091.750000 64010.0000 30.6012
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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 4 8.000000 600.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 17 33.500000 1859.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 21.500000 1612.5000 75.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.000000 145.5000 48.5000
Subtotal (Total Children Is Unduplicated) 97 214.250000 11796.5700 55.0598
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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 37 61.000000 3050.0000 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 4 5.000000 125.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 87 582.422000 29121.1000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 6.053624 410.9200 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 2 41.000000 2227.1200 54.3200
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 13.000000 650.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 70.586600 4791.4190 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 558 162914.0000 81378.0000 0.4995
Subtotal (Total Children Is Unduplicated) 563 164384.5622 156886.6390 0.9544
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Total 166690.562224 232693.2090 1.3960
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Number of Children (Unduplicated) With at Least One Service 768
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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 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 749 36924.053624 35257.0300 35257.0300
T 2363 52578.250000 66855.0900 66761.5900
4360 77179.258600 130131.0890 110.5000
Other 9 9.000000 450.0000 0.0000
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Total 7481 166690.562224 232693.2090 102129.1200