CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 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 866 375.750000 13902.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 516 535.750000 19822.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2332 6381.500000 236097.0000 36.9971
Subtotal (Total Children Is Unduplicated) 2383 7293.000000 269822.5000 36.9975
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 18 18.000000 826.0000 45.8889
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 27 37.000000 4625.0000 125.0000
EXIT-EXIT-TRANSITION ASSESSMENT 132 309.500000 15475.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 26 36.500000 2737.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 23 37.500000 2812.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 26 34.500000 1914.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 193 245.500000 18462.8000 75.2049
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 70 90.000000 6750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 180 236.500000 13125.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 219 337.500000 25275.0000 74.8889
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.000000 197.5000 39.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 15 15.000000 773.1000 51.5400
Subtotal (Total Children Is Unduplicated) 553 1408.000000 93360.9000 66.3075
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 20 82.000000 22272.5400 271.6163
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 126 201.500000 10075.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 30 32.000000 1600.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 15 11.000000 275.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.750000 137.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 1.250000 31.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 11 11.000000 550.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 13 10.000000 250.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 37 50.000000 2500.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 12 14.250000 356.2500 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 26 164.000000 4083.5000 24.8994
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 30 151.000000 7550.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 5 35.000000 1750.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 824 5512.000000 275620.7600 50.0038
INTR-INTR-INTERPRETER 87 496.250000 15505.0000 31.2443
OCCT-97530-OT SESSION BY LICENSED OT 20 133.250000 9066.9800 68.0449
OCCT-97530HM-OT SESSION BY OT ASST 1 3.750000 203.7000 54.3200
PHY-97110-PT SESSION BY LICENSED PT 91 608.000000 41632.9200 68.4752
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 14 117.500000 5875.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 205 1454.000000 98814.3590 67.9604
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.000000 26.4000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1258 323814.0000 161903.0000 0.5000
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 34 459.750000 22987.5000 50.0000
Subtotal (Total Children Is Unduplicated) 1342 333367.2500 683091.6590 2.0491
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Total 342068.250000 1046275.0590 3.0587
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Number of Children (Unduplicated) With at Least One Service 2514
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Center 01
Flag Claims Units Chgs Paid
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R 3 2.500000 92.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1580 1182.000000 46367.5000 0.0000
P 9113 210625.000000 378502.6700 378493.4200
D 238 207.000000 10390.5000 0.0000
S 22 26.000000 3025.0000 0.0000
H 51 67.000000 5400.0000 0.0000
T 2845 102246.000000 142798.3710 142802.1200
7698 16592.750000 406570.3480 0.0000
Other 711 11120.000000 53128.1700 0.0000
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Total 22261 342068.250000 1046275.0590 521295.5400