CMS/EIP Fiscal Report Center: 09
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 818 886.250000 32782.0000 36.9896
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 717 814.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 807 783.000000 28961.7500 36.9882
TCM-T1017TL-TARGETED CASE MANAGEMENT 1868 8089.750000 298960.0000 36.9554
TCON-TCON-TRANSITION CONFERENCE 172 174.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 1890 10747.00000 360703.7500 33.5632
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 103 188.000000 9400.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 66 125.000000 9375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 19.500000 1462.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 15 26.500000 1987.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 30 56.000000 4200.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 38 74.000000 4107.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 347 624.000000 46725.0000 74.8798
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 181 307.500000 22987.5000 74.7561
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 124 229.500000 17212.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 359 666.000000 36907.5000 55.4167
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 62 108.500000 8137.5000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 48.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.000000 242.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 145.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.000000 194.0000 48.5000
Subtotal (Total Children Is Unduplicated) 674 2437.500000 163132.5000 66.9262
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 3.000000 110.9000 36.9667
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 61 98.250000 4912.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 11 7.250000 181.2500 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 70 59.250000 2962.5000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 7 5.500000 137.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 6 8.500000 425.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 7 11.000000 550.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 69 70.000000 3500.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 5 3.500000 87.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 583 4523.250000 226162.5000 50.0000
INTR-INTR-INTERPRETER 182 317.250000 15837.5000 49.9212
OCCT-97530-OT SESSION BY LICENSED OT 219 1534.500000 103632.6400 67.5351
OCCT-97530HM-OT SESSION BY OT ASST 2 8.000000 434.5600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 313 2123.000000 142020.8900 66.8963
PHY-97110HM-PT SESSION BY PT ASST 17 108.250000 5834.3800 53.8973
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.000000 50.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 574 4506.250000 305582.7200 67.8131
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1014 255318.0000 127632.0000 0.4999
Subtotal (Total Children Is Unduplicated) 1302 268705.7500 940054.3400 3.4985
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Total 281890.250000 1463890.5900 5.1931
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Number of Children (Unduplicated) With at Least One Service 1959
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Center 09
Flag Claims Units Chgs Paid
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R 3 1.750000 64.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 6049 6091.750000 273080.4800 0.0000
P 14876 264609.500000 782756.5100 782889.5450
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
2802 11185.500000 407924.1000 831.4600
Other 3 1.750000 64.7500 0.0000
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Total 23733 281890.250000 1463890.5900 783721.0050