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
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 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 490 1920.750000 71067.7500 37.0000
TCON-TCON-TRANSITION CONFERENCE 1 1.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 740 2270.250000 83888.2500 36.9511
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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 2 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 121 144.000000 10800.0000 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 128 204.500000 11349.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 13.500000 1012.5000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 7 7.000000 339.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.000000 242.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.000000 145.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 6.000000 291.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 20 19.381400 940.0000 48.5001
Subtotal (Total Children Is Unduplicated) 263 509.881400 30658.0000 60.1277
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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 35 35.000000 1750.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 289 2559.250000 127962.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 96.500000 6550.4200 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 3 13.500000 733.3200 54.3200
PHY-97110-PT SESSION BY LICENSED PT 32 117.250000 7958.9300 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 2.000000 108.6400 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 108 537.671300 36497.1300 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 21 65.131800 3537.9600 54.3200
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 798 156867.0000 81790.9000 0.5214
Subtotal (Total Children Is Unduplicated) 874 160296.3031 267039.8000 1.6659
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Total 163076.434500 381586.0500 2.3399
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Number of Children (Unduplicated) With at Least One Service 1179
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Center 57
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 1 1.000000 37.0000 37.0000
D 14 11.000000 407.0000 0.0000
S 45 1289.500000 2778.1400 2778.1400
H 0 0.000000 0.0000 0.0000
T 3253 159058.184500 266752.2800 266752.2800
2862 2716.750000 111611.6300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6175 163076.434500 381586.0500 269567.4200