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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 4 4.000000 194.0000 48.5000
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 8 12.000000 1500.0000 125.0000
EXIT-EXIT-TRANSITION ASSESSMENT 4 7.500000 375.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 11.000000 825.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 10.500000 787.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 12.500000 693.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 49 62.500000 4779.1400 76.4662
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 23.500000 1762.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 45 64.500000 3579.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 53 80.000000 5962.5000 74.5313
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 1.750000 88.8000 50.7429
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 2.750000 184.4500 67.0727
Subtotal (Total Children Is Unduplicated) 137 295.000000 20893.3900 70.8251
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 8 12.000000 4855.4600 404.6217
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 10.500000 525.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 2.000000 100.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.250000 13.4100 53.6400
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 63 329.750000 16949.8800 51.4022
OCCT-97530-OT SESSION BY LICENSED OT 6 6.750000 511.9200 75.8400
PHY-97110-PT SESSION BY LICENSED PT 23 94.500000 7253.2400 76.7539
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 4.000000 200.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 59 247.750000 18673.1980 75.3711
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 47.000000 23.5000 0.5000
Subtotal (Total Children Is Unduplicated) 150 756.500000 49155.6080 64.9777
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Total 1051.500000 70048.9980 66.6182
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Number of Children (Unduplicated) With at Least One Service 264
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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 0 0.000000 0.0000 0.0000
P 18 40.500000 2348.5800 2348.5800
D 94 123.000000 7282.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 51 67.000000 5400.0000 0.0000
T 2 8.000000 450.0000 500.0000
514 618.250000 43200.5280 0.0000
Other 134 194.750000 11367.3900 0.0000
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Total 813 1051.500000 70048.9980 2848.5800