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
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 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 519 1926.750000 71289.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1108 2731.000000 83398.0000 30.5375
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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 3 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 1.000000 75.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 23 14.000000 1050.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 40 21.000000 1575.0000 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 27 21.000000 1575.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 10.500000 582.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 166 119.000000 8925.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.000000 225.5000 112.7500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 22.1400 22.1400
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 6.000000 291.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 14.000000 679.0000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.000000 242.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.000000 339.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 31 31.000000 1503.5000 48.5000
Subtotal (Total Children Is Unduplicated) 423 370.500000 23120.3900 62.4032
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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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 177 1461.500000 73075.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 72 446.000000 30274.4800 67.8800
PHY-97110-PT SESSION BY LICENSED PT 39 213.250000 14475.4100 67.8800
PHY-97110HM-PT SESSION BY PT ASST 4 21.000000 1140.7200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 39 253.000000 17173.6400 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 10 63.000000 3422.1600 54.3200
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) 1051 147918.2500 217398.4100 1.4697
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Total 151019.750000 323916.8000 2.1449
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Number of Children (Unduplicated) With at Least One Service 1499
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Center 04
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 2988 147371.250000 214300.7700 212607.5400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 191.000000 661.6000 661.6000
T 0 0.000000 0.0000 0.0000
3938 3428.500000 107094.3900 0.0000
Other 11 29.000000 1860.0400 1554.5800
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Total 6943 151019.750000 323916.8000 214823.7200