CMS/EIP Fiscal Report Center: 55
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 244 129.250000 4763.7500 36.8569
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 347 461.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 89 57.250000 2118.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 218 707.000000 25983.2500 36.7514
TCON-TCON-TRANSITION CONFERENCE 19 19.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 536 1373.500000 32865.2500 23.9281
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 8 15.500000 775.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 53 80.063200 6004.7400 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 29.029333 2177.2000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 9.000000 675.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 9.500000 527.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 33.000000 2475.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 10 10.000000 485.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 7.417500 359.7500 48.5002
Subtotal (Total Children Is Unduplicated) 88 196.510033 13703.9400 69.7366
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 1065.7500 532.8750
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 5 5.000000 250.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 17 22.750000 568.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 5 5.000000 250.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 11 19.500000 487.5000 25.0000
CONPP-CONPP-CONSULT, PT, PHONE 3 1.500000 37.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.250000 31.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 20 153.000000 7650.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 40 191.684586 13011.5500 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 5 15.000000 814.8000 54.3200
PHY-97110-PT SESSION BY LICENSED PT 27 147.583023 10017.8900 67.8797
PHY-97110HM-PT SESSION BY PT ASST 5 14.795100 803.6700 54.3200
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.000000 1000.0000 500.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 126 754.739981 51231.7596 67.8800
TRAN-TRAN-FAMILY TRANSPORTATION 2 102.000000 84.0000 0.8235
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 365 81256.00000 60311.2000 0.7422
Subtotal (Total Children Is Unduplicated) 394 82694.80269 147665.6196 1.7857
-----------------------------------------------------------------------------------------------------------------------
Total 84264.812723 194234.8096 2.3051
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 652
-----------------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 1.500000 55.5000 0.0000
P 1824 32043.529700 60781.2200 60781.2200
D 53 63.750000 3290.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2912 50670.478667 93419.8396 93419.8400
1812 1485.554356 36687.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6603 84264.812723 194234.8096 154201.0600