CMS/EIP Fiscal Report Center: 52
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 403 255.500000 9453.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 67 71.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 284 214.250000 7927.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 248 816.250000 30164.2500 36.9547
TCON-TCON-TRANSITION CONFERENCE 1 1.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 540 1358.000000 47545.0000 35.0110
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 4 4.000000 200.0000 50.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 44.000000 3300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 15.500000 1162.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.000000 525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 33 62.500000 3468.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.000000 242.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 97.0000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 8 8.000000 400.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 17 17.000000 824.5000 48.5000
Subtotal (Total Children Is Unduplicated) 80 172.500000 10665.7500 61.8304
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 2314.7700 2314.7700
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 57 64.000000 3200.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 29 30.000000 1500.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 9 5.250000 131.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 9 8.000000 400.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 6 2.250000 56.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 12 11.000000 550.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 6 3.750000 93.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 24 28.000000 1400.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.500000 12.5000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 35 187.250000 9362.5000 50.0000
INTR-INTR-INTERPRETER 8 95.000000 1168.7500 12.3026
OCCT-97530-OT SESSION BY LICENSED OT 23 92.166175 6256.2400 67.8800
PHY-97110-PT SESSION BY LICENSED PT 23 144.010000 9774.5400 67.8740
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 100 483.347549 32667.3200 67.5856
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 412 87288.00000 43594.0000 0.4994
Subtotal (Total Children Is Unduplicated) 428 88447.52372 112656.8700 1.2737
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Total 89978.023724 170867.6200 1.8990
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Number of Children (Unduplicated) With at Least One Service 593
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Center 52
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 388 18572.800212 19877.3900 19877.3900
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
4380 71266.223512 145422.0900 0.0000
Other 39 139.000000 5568.1400 0.0000
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Total 4807 89978.023724 170867.6200 19877.3900