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:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 6.000000 222.0000 37.0000
Subtotal (Total Children Is Unduplicated) 4 6.000000 222.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 1 2.000000 150.0000 75.0000
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EI Services,Class #03
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
ECE-ECE-EARLY CHILDHOOD EDUCATION 1 120.000000 120.0000 1.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.000000 200.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 10.500000 712.7400 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 3 6.000000 325.9200 54.3200
PHY-97110-PT SESSION BY LICENSED PT 2 4.750000 322.4300 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 14.500000 984.2600 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 0.500000 27.1600 54.3200
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 39 3043.000000 1573.5000 0.5171
Subtotal (Total Children Is Unduplicated) 50 3205.250000 4366.0100 1.3621
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Total 3213.250000 4738.0100 1.4745
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Number of Children (Unduplicated) With at Least One Service 55
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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 0 0.000000 0.0000 0.0000
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
112 3106.500000 3413.5400 0.0000
Other 15 106.750000 1324.4700 1324.4700
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Total 127 3213.250000 4738.0100 1324.4700