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: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 537 319.750000 11830.7500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 475 477.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 11 7.500000 277.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1650 6920.750000 256038.7500 36.9958
Subtotal (Total Children Is Unduplicated) 1674 7725.000000 268147.0000 34.7116
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 52 47.000000 2350.0000 50.0000
EXIT-EXIT-TRANSITION ASSESSMENT 67 62.500000 3125.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 2.500000 187.5000 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 42 45.000000 2497.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 121 64.000000 4800.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 3.500000 262.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 94 64.500000 4837.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 363 328.000000 18204.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 170 129.500000 9712.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 168 168.000000 30502.0000 181.5595
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 53 53.000000 2570.5000 48.5000
Subtotal (Total Children Is Unduplicated) 597 1097.000000 87573.6400 79.8301
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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 367 374.000000 2992.0000 8.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 826 145040.0000 72520.0000 0.5000
Subtotal (Total Children Is Unduplicated) 1202 161881.0000 781847.8000 4.8298
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Total 170703.000000 1137568.4400 6.6640
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Number of Children (Unduplicated) With at Least One Service 1807
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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 2403 2702.750000 102366.7500 0.0000
P 5457 149993.250000 330703.5200 325530.9500
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
5420 12028.250000 407017.0400 0.0000
Other 54 115.500000 7621.2000 7280.8000
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Total 15028 170703.000000 1137568.4400 621467.2700