CMS/EIP Fiscal Report Center: 57
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 222 131.750000 4874.7500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 237 214.750000 7945.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1221 4961.750000 183584.7500 37.0000
TCON-TCON-TRANSITION CONFERENCE 1 1.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 1233 5311.250000 196405.2500 36.9791
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 3.000000 150.0000 50.0000
EXIT-EXIT-TRANSITION ASSESSMENT 94 94.500000 4725.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 15.500000 1162.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 23.000000 1276.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 262 303.000000 22725.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 287 439.000000 24364.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 39.000000 2925.0000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 20 20.000000 970.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 8 8.000000 388.0000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 11 11.000000 533.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 14 15.000000 727.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 66 66.000000 3201.0000 48.5000
Subtotal (Total Children Is Unduplicated) 485 1043.500000 63636.0000 60.9832
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EI Services,Class #03
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 3.000000 150.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 37 37.000000 1850.0000 50.0000
ECE-ECE-EARLY CHILDHOOD EDUCATION 118 18680.00000 18680.0000 1.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 269.000000 6725.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 767 7012.000000 350600.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 144 892.000000 60548.9600 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 3 19.500000 1059.2400 54.3200
PHY-97110-PT SESSION BY LICENSED PT 154 779.500000 52912.4600 67.8800
PHY-97110HM-PT SESSION BY PT ASST 7 33.500000 1819.7200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 289 1647.500000 111832.3000 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 28 93.500000 5078.9200 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 2 5.500000 72.6000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 835 159948.0000 83383.4000 0.5213
Subtotal (Total Children Is Unduplicated) 1035 189420.0000 694712.6000 3.6676
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Total 195774.750000 954753.8500 4.8768
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Number of Children (Unduplicated) With at Least One Service 1395
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Center 57
Flag Claims Units Chgs Paid
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R 83 88.500000 3274.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1242 1310.500000 58766.7500 0.0000
P 2080 2028.315500 75459.4900 75380.0700
D 15 13.000000 481.0000 0.0000
S 45 1289.500000 2778.1400 2778.1400
H 0 0.000000 0.0000 0.0000
T 3267 159107.684500 269359.8800 269359.8800
5754 31830.500000 543309.6200 343390.3600
Other 15 106.750000 1324.4700 1324.4700
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Total 12501 195774.750000 954753.8500 692232.9200