CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 Page: 1
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 620 538.500000 19924.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 360 361.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 11 15.250000 564.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1449 4724.500000 174806.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1480 5639.250000 195295.2500 34.6314
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 67 64.500000 3225.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 87 76.500000 3825.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 7.000000 525.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 3.500000 262.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 9.000000 675.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 20.000000 1110.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 66 34.500000 2587.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 6.000000 450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 82 56.500000 4237.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 243 209.000000 11599.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 131 101.000000 7575.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 126 126.000000 11175.8900 88.6975
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 23 23.000000 1486.0800 64.6122
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 15 15.000000 727.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 61 61.000000 2958.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 12 12.000000 582.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 22 22.000000 1067.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 47 47.000000 2279.5000 48.5000
Subtotal (Total Children Is Unduplicated) 515 896.500000 56546.9700 63.0753
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 26 45.750000 2287.5000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 4.000000 200.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 9 9.000000 450.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 5 5.000000 250.0000 50.0000
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 4 632.000000 15800.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 82 2846.000000 71150.0000 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 5.000000 250.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 949 8803.750000 440137.5000 49.9943
OCCT-97530-OT SESSION BY LICENSED OT 163 1072.000000 72767.3600 67.8800
PHY-97110-PT SESSION BY LICENSED PT 132 662.250000 44953.5300 67.8800
PHY-97110HM-PT SESSION BY PT ASST 3 4.500000 244.4400 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 108 575.500000 38955.5800 67.6900
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 34.000000 1846.8800 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.2000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 323 329.000000 2632.0000 8.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 961 184520.0000 92260.0000 0.5000
Subtotal (Total Children Is Unduplicated) 1182 199550.7500 784297.9900 3.9303
-----------------------------------------------------------------------------------------------------------------------
Total 206086.500000 1036140.2100 5.0277
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1655
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 23 31.750000 1174.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 925 1100.500000 42436.7500 0.0000
P 6187 189982.500000 365291.4900 358360.0600
D 22 27.750000 1026.7500 249.7500
S 0 0.000000 0.0000 0.0000
H 2141 7325.000000 361215.2800 360811.3000
T 0 0.000000 0.0000 0.0000
4183 7531.750000 259430.3000 0.0000
Other 49 87.250000 5564.8900 2290.8600
---------------------------------------------------------
Total 13530 206086.500000 1036140.2100 721711.9700