CMS/EIP Fiscal Report Center: 07
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 1041 860.250000 31829.2500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 56 58.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 645 909.750000 33660.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 626 1829.750000 67700.7500 37.0000
TCON-TCON-TRANSITION CONFERENCE 17 17.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 1349 3674.750000 133190.7500 36.2448
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 6.000000 322.0000 53.6667
EXIT-EXIT-TRANSITION ASSESSMENT 29 43.250000 2162.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 47.500000 3562.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 5.000000 375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 62 120.000000 6660.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 78 187.000000 14025.0000 75.0000
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 72.7800 72.7800
NUTR-97802-NUTRITIONAL EVAL, INITIAL 3 2.000000 100.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 2 1.000000 50.0000 50.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 77.0000 38.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 145.5000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 6 6.000000 300.0000 50.0000
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 2 3.000000 45.0000 15.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.000000 145.5000 48.5000
Subtotal (Total Children Is Unduplicated) 146 440.750000 28799.5300 65.3421
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 26 33.000000 1650.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 2 2.000000 50.0000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 20 30.500000 1525.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 13 8.000000 200.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 15 33.500000 1675.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 11 12.250000 612.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.750000 18.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 28 43.750000 2187.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 3 1.250000 31.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 238 1659.000000 82220.8900 49.5605
INTR-INTR-INTERPRETER 2 3.500000 175.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 18 106.750000 6139.6100 57.5139
PHY-97110-PT SESSION BY LICENSED PT 20 89.750000 4807.4400 53.5648
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 73 513.000000 34110.1900 66.4916
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 776 156562.0000 78266.0000 0.4999
Subtotal (Total Children Is Unduplicated) 862 159101.0000 213705.1300 1.3432
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Total 163216.500000 375695.4100 2.3018
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Number of Children (Unduplicated) With at Least One Service 1502
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Center 07
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 2899 153660.250000 218745.8100 218745.8100
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
6606 9556.250000 156949.6000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 9505 163216.500000 375695.4100 218745.8100