CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 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 461 335.750000 12274.7500 36.5592
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 243 306.250000 11266.5000 36.7886
TCM-T1017TL-TARGETED CASE MANAGEMENT 565 1059.750000 38739.0000 36.5548
Subtotal (Total Children Is Unduplicated) 604 1701.750000 62280.2500 36.5978
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Screening, Eval, and Assessment,Class #02
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 23.4500 23.4500
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 3.500000 175.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 26 27.000000 1350.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 11.000000 825.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 12.000000 900.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.500000 412.5000 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 83 151.500000 11362.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 49.500000 3712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 42 78.500000 4356.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 46 90.000000 6750.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 145.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 97.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 147 447.500000 30824.7000 68.8820
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 5.000000 160.0000 32.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 14 15.750000 787.5000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 18 13.500000 675.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 19 14.000000 700.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 21 19.750000 987.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 55 316.500000 15825.0000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 16.000000 800.0000 50.0000
INTR-INTR-INTERPRETER 18 51.000000 2430.0000 47.6471
OCCT-97530-OT SESSION BY LICENSED OT 21 124.250000 8348.3600 67.1900
PHY-97110-PT SESSION BY LICENSED PT 18 58.250000 3532.2600 60.6397
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 64 452.500000 30715.7000 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 430 68160.00000 34080.0000 0.5000
Subtotal (Total Children Is Unduplicated) 446 69247.50000 99091.3200 1.4310
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Total 71396.750000 192196.2700 2.6919
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Number of Children (Unduplicated) With at Least One Service 728
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Center 02
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 787 551.000000 20063.2500 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 0 0.000000 0.0000 0.0000
T 1008 35509.000000 55495.8800 55495.8800
3264 35336.750000 116637.1400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5059 71396.750000 192196.2700 55495.8800