CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 483 290.250000 10739.2500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 325 327.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 11 7.500000 277.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1427 5819.500000 215292.5000 36.9950
Subtotal (Total Children Is Unduplicated) 1447 6444.250000 226309.2500 35.1180
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 46 41.500000 2075.0000 50.0000
EXIT-EXIT-TRANSITION ASSESSMENT 67 62.500000 3125.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 3.500000 262.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 26 24.500000 1837.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 40 43.000000 2386.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 58 31.500000 2362.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 1.000000 75.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 70 48.500000 3637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 225 206.500000 11460.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 114 87.000000 6525.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 115 115.000000 20841.5000 181.2304
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 25 25.000000 2542.1400 101.6856
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 10 10.000000 485.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 22 22.000000 1067.0000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 12 12.000000 582.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 26 26.000000 1261.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 49 49.000000 2376.5000 48.5000
Subtotal (Total Children Is Unduplicated) 447 816.500000 63502.3900 77.7739
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 19 32.500000 1625.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 5 5.000000 250.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 5.000000 250.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 40 3872.000000 96800.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 98 2736.000000 68400.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 822 6982.500000 349125.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 199 1112.750000 75533.4700 67.8800
PHY-97110-PT SESSION BY LICENSED PT 176 838.000000 56883.4400 67.8800
PHY-97110HM-PT SESSION BY PT ASST 8 28.500000 1548.1200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 152 754.250000 51198.4900 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 15 79.000000 4291.2800 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 15 17.500000 231.0000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 272 278.000000 2224.0000 8.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 826 145040.0000 72520.0000 0.5000
Subtotal (Total Children Is Unduplicated) 1107 161785.0000 781079.8000 4.8279
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Total 169045.750000 1070891.4400 6.3349
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Number of Children (Unduplicated) With at Least One Service 1580
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Center 04
Flag Claims Units Chgs Paid
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R 1 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2112 2350.250000 88450.2500 0.0000
P 5139 149596.250000 310094.7700 305061.0100
D 23 26.000000 999.5000 148.0000
S 0 0.000000 0.0000 0.0000
H 1670 5836.500000 288832.6800 288507.5200
T 0 0.000000 0.0000 0.0000
4568 11120.500000 374865.2900 0.0000
Other 54 115.500000 7621.2000 7280.8000
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Total 13567 169045.750000 1070891.4400 600997.3300