CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2011 ending 09/30/2011 Date of Report:12/01/2011 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 402 264.500000 9777.2500 36.9650
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 333 386.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 442 428.250000 15817.5000 36.9352
TCM-T1017TL-TARGETED CASE MANAGEMENT 219 583.500000 21487.7500 36.8256
TCON-TCON-TRANSITION CONFERENCE 47 48.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 659 1710.250000 47082.5000 27.5296
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.000000 97.0000 48.5000
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 2 2.000000 200.0000 100.0000
EXIT-EXIT-TRANSITION ASSESSMENT 54 97.250000 4862.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 14.000000 1050.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 14.000000 777.0000 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 15.500000 1162.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 10.000000 750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 27.500000 1526.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 35.000000 2625.0000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 2 2.000000 100.0000 50.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.000000 291.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 8.000000 388.0000 48.5000
Subtotal (Total Children Is Unduplicated) 102 240.250000 14276.2500 59.4225
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 3.000000 344.6600 114.8867
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 146 216.750000 10825.0000 49.9423
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 52 83.500000 2087.5000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 135 351.250000 17550.0000 49.9644
CONIP-CONIP-CONSULT, ITDS, PHONE 35 29.750000 743.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 18 14.750000 737.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 8 6.750000 168.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 36 41.000000 2050.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 8 5.250000 131.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 36 55.250000 2762.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 16 8.250000 206.2500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 6 24.500000 1796.3400 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 7 9.500000 237.5000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 7 35.000000 1750.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 102 534.377800 26718.8900 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 25.000000 1250.0000 50.0000
INTR-INTR-INTERPRETER 5 8.250000 412.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 15 69.750000 4734.6300 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 1 2.000000 108.6400 54.3200
PHY-97110-PT SESSION BY LICENSED PT 19 98.436190 6681.8484 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 4.000000 217.2800 54.3200
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 4.000000 200.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 37 252.912340 17167.6896 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 2 1.000000 13.2000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 608 176557.0000 88065.7500 0.4988
Subtotal (Total Children Is Unduplicated) 610 178441.2263 186961.4280 1.0477
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Total 180391.726330 248320.1780 1.3766
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Number of Children (Unduplicated) With at Least One Service 792
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Center 53
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 1 0.500000 18.5000 18.5000
D 56 44.750000 1604.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1228 45986.348700 52215.0598 52215.0600
T 2369 51489.250000 71660.5400 71584.7900
4087 82870.877630 122822.0782 82.5000
Other 0 0.000000 0.0000 0.0000
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Total 7741 180391.726330 248320.1780 123900.8500