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
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 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 193 342.250000 12663.2500 37.0000
TCON-TCON-TRANSITION CONFERENCE 31 31.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 483 835.500000 26214.5000 31.3758
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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 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 19.000000 1425.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 23.000000 1276.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 0.188700 14.1500 74.9868
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 36 85.688700 4659.9000 54.3817
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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 72 85.000000 4237.5000 49.8529
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 4.000000 200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 58 173.565600 8678.2800 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 2.000000 100.0000 50.0000
INTR-INTR-INTERPRETER 4 47.000000 940.0000 20.0000
OCCT-97530-OT SESSION BY LICENSED OT 8 16.335800 1108.8700 67.8797
OCCT-97530HM-OT SESSION BY OT ASST 2 3.500000 190.1200 54.3200
PHY-97110-PT SESSION BY LICENSED PT 18 38.665400 2624.5600 67.8788
PHY-97110HM-PT SESSION BY PT ASST 2 2.000000 108.6400 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 86.750000 5888.5900 67.8800
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) 569 72311.06680 62313.5600 0.8617
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Total 73232.255500 93187.9600 1.2725
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Number of Children (Unduplicated) With at Least One Service 757
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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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 3 1.250000 46.2500 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
109 3910.538200 4729.4800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2846 73232.255500 93187.9600 88412.2300