CMS/EIP Fiscal Report Center: 55
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 222 116.250000 4264.2500 36.6817
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 301 390.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 68 48.750000 1803.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 681 2214.500000 81289.5000 36.7078
TCON-TCON-TRANSITION CONFERENCE 18 19.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 685 2788.500000 87357.5000 31.3278
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 4 8.000000 1000.0000 125.0000
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.500000 75.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 8.500000 637.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 114 190.000000 14250.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 61 110.500000 8250.0000 74.6606
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 34.000000 2550.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 19.500000 1082.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 82 122.500000 9187.5000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.000000 145.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 25 25.000000 1212.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.000000 194.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.000000 194.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 14 14.000000 679.0000 48.5000
Subtotal (Total Children Is Unduplicated) 186 556.000000 40290.5000 72.4649
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 4.000000 2333.3500 583.3375
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 12 9.000000 450.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.250000 6.2500 25.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 14 7.250000 181.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 3 3.000000 150.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 3 1.500000 37.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 3.250000 162.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 7 3.500000 87.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 14 7.000000 350.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 12 6.250000 156.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 89 643.000000 32150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 101 615.250004 41763.1700 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 14 81.000000 4399.9200 54.3200
PHY-97110-PT SESSION BY LICENSED PT 61 327.000000 22162.8200 67.7762
PHY-97110HM-PT SESSION BY PT ASST 21 78.000000 4236.9600 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 261 1770.250000 120164.5700 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 350 82680.00000 62525.2000 0.7562
Subtotal (Total Children Is Unduplicated) 395 86239.50000 291317.2400 3.3780
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Total 89584.000004 418965.2400 4.6768
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Number of Children (Unduplicated) With at Least One Service 769
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Center 55
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 28 30.500000 1100.7500 0.0000
P 5308 61612.193166 173371.2200 173258.7200
D 36 36.250000 1968.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 3 4.500000 337.5000 0.0000
T 1643 24069.441636 50590.2100 50590.2100
4446 3831.115202 191597.3100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11464 89584.000004 418965.2400 223848.9300