CMS/EIP Fiscal Report Center: 55
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 244 129.250000 4763.7500 36.8569
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 347 461.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 89 57.250000 2118.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 771 2568.250000 94581.0000 36.8270
TCON-TCON-TRANSITION CONFERENCE 19 19.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 772 3234.750000 101463.0000 31.3666
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.3400 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.7300 21.7300
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 8 15.500000 775.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.000000 450.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 118 193.000000 14475.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 73 129.000000 9675.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 26 39.000000 2925.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 42.500000 2358.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 95 142.000000 10650.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 25 25.000000 1212.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.000000 436.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 24 25.000000 1212.5000 48.5000
Subtotal (Total Children Is Unduplicated) 213 640.500000 45189.5700 70.5536
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 4.000000 1327.6500 331.9125
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 5 5.000000 250.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 17 22.750000 568.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 5 5.000000 250.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 11 19.500000 487.5000 25.0000
CONPP-CONPP-CONSULT, PT, PHONE 3 1.500000 37.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.250000 31.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 86 630.500000 31525.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 93 533.250000 36197.0100 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 15 71.500000 3897.4400 54.5097
PHY-97110-PT SESSION BY LICENSED PT 64 348.000007 23622.1800 67.8798
PHY-97110HM-PT SESSION BY PT ASST 24 88.000000 4780.1600 54.3200
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.000000 1000.0000 500.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 272 1757.986600 119332.1296 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.750000 9.9000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 2 102.000000 84.0000 0.8235
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 365 81256.00000 60311.2000 0.7422
Subtotal (Total Children Is Unduplicated) 432 84849.98661 283761.6696 3.3443
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Total 88725.236607 430414.2396 4.8511
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Number of Children (Unduplicated) With at Least One Service 797
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Center 55
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 61 68.250000 2582.2500 0.0000
P 3763 33920.529700 134131.4700 134131.4700
D 53 63.750000 3290.7500 0.0000
S 4 3.500000 129.5000 0.0000
H 1 1.500000 112.5000 0.0000
T 2912 50670.478667 93419.8396 93419.8400
4587 3997.228240 196747.9300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11381 88725.236607 430414.2396 227551.3100