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
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 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 793 3176.750000 117299.2500 36.9243
TCON-TCON-TRANSITION CONFERENCE 172 174.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 1568 5834.000000 179043.0000 30.6896
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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 4 8.000000 600.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 38.500000 2887.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 21.000000 1575.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 19.500000 1462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 49.500000 2747.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 145.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.000000 145.5000 48.5000
Subtotal (Total Children Is Unduplicated) 145 347.500000 20133.7500 57.9388
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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 97.250000 4862.5000 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 212 1634.500000 81725.0000 50.0000
INTR-INTR-INTERPRETER 182 317.250000 15837.5000 49.9212
OCCT-97530-OT SESSION BY LICENSED OT 114 844.500000 56795.4400 67.2533
OCCT-97530HM-OT SESSION BY OT ASST 2 8.000000 434.5600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 143 1002.250000 65944.3800 65.7963
PHY-97110HM-PT SESSION BY PT ASST 9 44.750000 2385.0600 53.2974
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.000000 50.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 361 2980.250000 201997.8400 67.7788
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1014 255318.0000 127632.0000 0.4999
Subtotal (Total Children Is Unduplicated) 1214 262415.7500 565618.9300 2.1554
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Total 268597.250000 764795.6800 2.8474
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Number of Children (Unduplicated) With at Least One Service 1772
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Center 09
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 14341 263949.500000 753885.7400 753885.7400
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
187 4647.750000 10909.9400 831.4600
Other 0 0.000000 0.0000 0.0000
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Total 14528 268597.250000 764795.6800 754717.2000