CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 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 248 170.500000 6308.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 74 76.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 185 190.000000 7030.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 117 205.500000 7603.5000 37.0000
TCON-TCON-TRANSITION CONFERENCE 14 14.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 375 656.000000 20942.0000 31.9238
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 18 152.000000 7600.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 11.500000 638.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.500000 562.5000 75.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.000000 97.0000 48.5000
Subtotal (Total Children Is Unduplicated) 27 179.000000 9347.7500 52.2221
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 312.0000 312.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 34 50.750000 2537.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 7 3.250000 81.2500 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 82 85.750000 4287.5000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 6 3.000000 75.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 11 14.000000 700.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 18 16.750000 837.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 1.250000 31.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 23 24.500000 1225.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 9 11.000000 806.5200 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 73 228.625000 11431.2500 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 8.000000 543.0400 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 1 8.000000 434.5600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 67.8800 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 2.000000 100.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 12.188700 827.3690 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 415 57662.00000 28831.0000 0.5000
Subtotal (Total Children Is Unduplicated) 422 58136.06370 53203.6190 0.9152
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Total 58971.063700 83493.3690 1.4158
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Number of Children (Unduplicated) With at Least One Service 578
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Center 53
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 2439 55869.736000 78757.8300 78716.8300
T 0 0.000000 0.0000 0.0000
117 3101.327700 4735.5390 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2556 58971.063700 83493.3690 78716.8300