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
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 866 375.750000 13902.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 516 535.750000 19822.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 797 2180.250000 80678.5000 37.0042
Subtotal (Total Children Is Unduplicated) 1546 3091.750000 114404.0000 37.0030
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 14 14.000000 632.0000 45.1429
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 3 4.000000 500.0000 125.0000
EXIT-EXIT-TRANSITION ASSESSMENT 128 302.000000 15100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 8.500000 637.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 37 48.000000 3558.6600 74.1388
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 8.500000 637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 31.500000 1748.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 53.500000 4012.5000 75.0000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 3.250000 108.7000 33.4462
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 7.250000 346.1500 47.7448
Subtotal (Total Children Is Unduplicated) 236 490.000000 27876.7600 56.8913
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 8 28.000000 10403.4700 371.5525
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 121 191.000000 9550.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 28 29.000000 1450.0000 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 1 0.250000 6.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 11 10.750000 536.5900 49.9153
CONPP-CONPP-CONSULT, PT, PHONE 12 9.000000 225.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 30 40.250000 2012.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 12 14.250000 356.2500 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 22 110.000000 2750.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 30 151.000000 7550.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 304 1752.500000 87183.3800 49.7480
INTR-INTR-INTERPRETER 87 496.250000 15505.0000 31.2443
OCCT-97530-OT SESSION BY LICENSED OT 17 125.500000 8487.1800 67.6269
OCCT-97530HM-OT SESSION BY OT ASST 1 3.750000 203.7000 54.3200
PHY-97110-PT SESSION BY LICENSED PT 66 446.750000 29848.6900 66.8130
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 14 109.500000 5475.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 153 947.750000 62594.1810 66.0450
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.000000 26.4000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1258 323697.0000 161844.5000 0.5000
Subtotal (Total Children Is Unduplicated) 1306 328179.2500 406445.5910 1.2385
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Total 331761.000000 548726.3510 1.6540
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Number of Children (Unduplicated) With at Least One Service 2060
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Center 01
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 1 50.000000 25.0000 0.0000
P 4741 207245.250000 247898.3400 247898.3400
D 33 12.250000 453.2500 0.0000
S 1 2.000000 250.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2842 102236.750000 142302.1210 142302.1200
5558 11610.000000 138861.2800 0.0000
Other 346 10604.750000 18936.3600 0.0000
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Total 13522 331761.000000 548726.3510 390200.4600