CMS/EIP Fiscal Report Center: 05
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 197 82.500000 3052.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 323 364.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 352 318.250000 11775.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 307 1118.750000 41366.0000 36.9752
Subtotal (Total Children Is Unduplicated) 628 1883.500000 56193.7500 29.8347
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 21 40.000000 1680.0000 42.0000
EXIT-EXIT-TRANSITION ASSESSMENT 42 70.000000 3500.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.000000 117.0000 58.5000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 2.2500 1.5000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.000000 229.5000 114.7500
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 41 56.000000 1956.0000 34.9286
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 17.000000 244.3800 14.3753
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 9.500000 430.5000 45.3158
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 29 41.500000 2303.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 84 106.000000 9579.0000 90.3679
Subtotal (Total Children Is Unduplicated) 182 347.500000 20152.8800 57.9939
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 97 111.000000 5567.5000 50.1577
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.250000 6.2500 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 258 293.250000 14662.5000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 18 7.000000 175.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 42 46.500000 2410.0000 51.8280
CONOP-CONOP-CONSULT, OT, PHONE 2 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 68 46.250000 2312.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 7 3.000000 75.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 142 130.250000 6632.5000 50.9213
CONSP-CONSP-CONSULT, SLP, PHONE 3 1.500000 37.5000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 26 108.500000 2503.8200 23.0767
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 184 947.500000 46296.4800 48.8617
INTR-INTR-INTERPRETER 13 143.000000 7150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 20.500000 1131.5200 55.1961
PHY-97110-PT SESSION BY LICENSED PT 18 119.750000 7322.9000 61.1516
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 37 149.750000 9566.3700 63.8823
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 485 110571.0000 55557.7500 0.5025
Subtotal (Total Children Is Unduplicated) 494 112700.0000 161432.5900 1.4324
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Total 114931.000000 237779.2200 2.0689
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Number of Children (Unduplicated) With at Least One Service 724
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Center 05
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 3186 95307.500000 136807.9700 136807.9700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3924 19623.500000 100971.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7110 114931.000000 237779.2200 136807.9700