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
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 461 335.000000 12247.0000 36.5582
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 242 304.250000 11192.5000 36.7872
TCM-T1017TL-TARGETED CASE MANAGEMENT 178 307.500000 11229.5000 36.5187
Subtotal (Total Children Is Unduplicated) 535 946.750000 34669.0000 36.6190
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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 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 54.500000 4087.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 9.500000 712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 29.000000 1609.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 46.000000 3450.0000 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) 84 190.000000 12672.4500 66.6971
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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 55 314.500000 15725.0000 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 69245.50000 98991.3200 1.4296
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Total 70382.250000 146332.7700 2.0791
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Number of Children (Unduplicated) With at Least One Service 703
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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 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 0 0.000000 0.0000 0.0000
T 1007 35508.000000 55445.8800 55445.8800
2868 34874.250000 90886.8900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3875 70382.250000 146332.7700 55445.8800