CMS/EIP Fiscal Report Center: 54
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 173 63.250000 2340.2500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 94 96.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 261 303.000000 11211.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 701 1190.000000 44030.0000 37.0000
TCON-TCON-TRANSITION CONFERENCE 31 31.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 724 1683.250000 57581.2500 34.2084
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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) 4 4.000000 37.3600 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.000000 86.9200 21.7300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 24.4700 24.4700
EXIT-EXIT-EXIT ASSESSMENT 15 28.500000 1425.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 5.500000 412.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 7.000000 525.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 19.500000 1082.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 36 60.500000 4537.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 32.000000 2400.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 6.500000 487.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 62 103.000000 5716.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 21.500000 1612.5000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 2.000000 97.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.000000 194.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 145.5000 48.5000
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 7.000000 339.5000 48.5000
Subtotal (Total Children Is Unduplicated) 121 318.500000 19784.5000 62.1177
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 10 7.500000 375.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 2 0.500000 12.5000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 74 105.500000 5262.5000 49.8815
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.500000 12.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 7 6.250000 312.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 10 10.750000 537.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 21 19.750000 987.5000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 6.000000 300.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 383 1232.750000 61637.5000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 10 12.000000 600.0000 50.0000
INTR-INTR-INTERPRETER 4 47.000000 940.0000 20.0000
OCCT-97530-OT SESSION BY LICENSED OT 28 104.500000 7079.9000 67.7502
OCCT-97530HM-OT SESSION BY OT ASST 3 5.000000 271.6000 54.3200
PHY-97110-PT SESSION BY LICENSED PT 49 176.000000 11946.8800 67.8800
PHY-97110HM-PT SESSION BY PT ASST 3 22.000000 1195.0400 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 68 233.250000 15833.0100 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.000000 54.3200 54.3200
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 560 71803.00000 35799.5000 0.4986
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 2 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 575 73797.25000 143357.7500 1.9426
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Total 75799.000000 220723.5000 2.9120
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Number of Children (Unduplicated) With at Least One Service 858
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Center 54
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 196 209.250000 11584.4100 0.0000
P 1408 955.584100 38088.7400 38330.6700
D 4 1.750000 64.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 2734 69320.467300 88412.2300 88412.2300
T 0 0.000000 0.0000 0.0000
1508 5296.698600 81715.1200 0.0000
Other 14 15.250000 858.2500 0.0000
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Total 5864 75799.000000 220723.5000 126742.9000