CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 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 96 48.500000 1794.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 135 106.750000 3949.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 924 2622.250000 97023.2500 37.0000
Subtotal (Total Children Is Unduplicated) 931 2777.500000 102767.5000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 3.500000 175.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 108 108.000000 5400.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 11.500000 862.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 6.500000 487.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 19.500000 1082.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 221 286.000000 21450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 274 430.500000 23892.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 94 135.000000 10125.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 25 25.000000 1212.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 18 18.000000 873.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 43 46.000000 2231.0000 48.5000
Subtotal (Total Children Is Unduplicated) 481 1095.000000 68204.0000 62.2868
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EI Services,Class #03
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 18 18.000000 900.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 94 95.000000 4750.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 20 994.000000 24850.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 739 6819.000000 340950.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 119 820.750000 55712.5100 67.8800
PHY-97110-PT SESSION BY LICENSED PT 134 707.750000 48042.0700 67.8800
PHY-97110HM-PT SESSION BY PT ASST 7 29.500000 1602.4400 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 234 1361.500000 92418.6200 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 0.500000 27.1600 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 5 6.000000 79.2000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 1 120.000000 60.0000 0.5000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 754 151257.0000 78981.5000 0.5222
Subtotal (Total Children Is Unduplicated) 1029 162231.0000 648473.5000 3.9972
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Total 166103.500000 819445.0000 4.9333
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Number of Children (Unduplicated) With at Least One Service 1319
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Center 57
Flag Claims Units Chgs Paid
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R 2 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1153 1091.250000 45721.7500 0.0000
P 875 973.622300 44378.4300 44378.4300
D 8 8.750000 399.7500 0.0000
S 112 5131.000000 6318.3200 6638.3200
H 5 7.750000 495.7500 0.0000
T 2954 149035.127700 242655.7000 243225.9400
4004 9689.000000 478983.9600 309501.8900
Other 12 166.000000 454.3400 454.3400
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Total 9125 166103.500000 819445.0000 604198.9200