CMS/EIP Fiscal Report Center: 03
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 1492 2690.500000 99548.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 399 439.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 398 365.750000 13532.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 816 1333.000000 49321.0000 37.0000
TCON-TCON-TRANSITION CONFERENCE 94 94.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 1519 4922.250000 162402.2500 32.9935
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 6 6.000000 291.0000 48.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 51 52.000000 473.7200 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 21 21.000000 196.1400 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 54 55.000000 1195.1500 21.7300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 48.9400 24.4700
EXIT-EXIT-EXIT ASSESSMENT 53 74.000000 3700.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 15.000000 1125.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 26.000000 1443.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 121 194.000000 14531.2500 74.9034
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 146 245.500000 18412.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 18 30.000000 2231.2500 74.3750
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 281 478.500000 26556.7500 55.5000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 2.1800 2.1800
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.000000 276.2700 46.0450
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 145.5000 48.5000
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 11 11.000000 506.5000 46.0455
Subtotal (Total Children Is Unduplicated) 418 1231.000000 71910.1500 58.4160
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 11 46.000000 3045.6800 66.2104
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 194 199.750000 9995.0000 50.0375
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 5 2.750000 68.7500 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 97 131.000000 6550.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 9 4.250000 106.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 63 83.750000 4187.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.500000 12.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 53 78.000000 3900.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 114 141.500000 7075.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 9 4.000000 100.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 177 1378.000000 64161.5000 46.5613
INTR-INTR-INTERPRETER 32 577.250000 24530.2800 42.4951
OCCT-97530-OT SESSION BY LICENSED OT 52 396.000000 23295.9400 58.8281
PHY-97110-PT SESSION BY LICENSED PT 41 328.250000 18258.7000 55.6244
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 27.8800 27.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 61 512.500000 23361.0600 45.5826
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 663 158137.0000 79014.0000 0.4997
Subtotal (Total Children Is Unduplicated) 702 162022.5000 267715.0400 1.6523
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Total 168175.750000 502027.4400 2.9851
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Number of Children (Unduplicated) With at Least One Service 1583
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Center 03
Flag Claims Units Chgs Paid
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R 12 7.500000 277.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 390 313.750000 14148.0000 0.0000
P 5310 60530.250000 145775.5700 145811.5700
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 0 0.000000 0.0000 0.0000
13883 107194.250000 339912.4200 0.0000
Other 130 130.000000 1913.9500 0.0000
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Total 19725 168175.750000 502027.4400 145811.5700