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
Payclass Filters:GR
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 347 1014.250000 37527.2500 37.0000
Subtotal (Total Children Is Unduplicated) 969 1929.000000 58016.0000 30.0757
-----------------------------------------------------------------------------------------------------------------------
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 4 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 9.500000 712.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 1.000000 75.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 18 15.000000 1125.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 22.500000 1248.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 105 67.500000 5062.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 182.2600 45.5650
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 6.000000 291.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 44 44.000000 2134.0000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.000000 194.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.000000 388.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 31 31.000000 1503.5000 48.5000
Subtotal (Total Children Is Unduplicated) 382 365.500000 20801.0100 56.9111
-----------------------------------------------------------------------------------------------------------------------
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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 195 1640.750000 82037.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 106 730.000000 49552.4000 67.8800
PHY-97110-PT SESSION BY LICENSED PT 39 243.000000 16494.8400 67.8800
PHY-97110HM-PT SESSION BY PT ASST 2 4.000000 217.2800 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 205.500000 13949.3400 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 34.000000 1846.8800 54.3200
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) 1088 187772.0000 262277.7400 1.3968
-----------------------------------------------------------------------------------------------------------------------
Total 190066.500000 341094.7500 1.7946
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1402
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 3889 187325.000000 262206.4000 259237.3200
D 21 27.250000 1008.2500 249.7500
S 0 0.000000 0.0000 0.0000
H 6 186.000000 407.8800 407.8800
T 0 0.000000 0.0000 0.0000
2963 2510.250000 76269.7600 0.0000
Other 9 18.000000 1202.4600 339.4000
---------------------------------------------------------
Total 6888 190066.500000 341094.7500 260234.3500