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: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 678 590.000000 21830.0000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 486 487.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 11 15.250000 564.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1621 5552.000000 205424.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1657 6644.250000 227818.2500 34.2880
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 70 67.000000 3350.0000 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 11 9.500000 712.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 21 21.000000 1165.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 96 50.000000 3750.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 8.500000 637.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 117 79.000000 5925.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 357 300.500000 16677.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 191 143.000000 10725.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 186 186.000000 18311.9600 98.4514
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 52 52.000000 2522.0000 48.5000
Subtotal (Total Children Is Unduplicated) 642 1139.500000 75409.2900 66.1775
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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 417 427.000000 3416.0000 8.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 961 184520.0000 92260.0000 0.5000
Subtotal (Total Children Is Unduplicated) 1276 199648.7500 785081.9900 3.9323
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Total 207432.500000 1088309.5300 5.2466
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Number of Children (Unduplicated) With at Least One Service 1832
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Center 04
Flag Claims Units Chgs Paid
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R 25 34.500000 1276.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 999 1219.500000 47168.5000 0.0000
P 6430 190339.500000 379320.6200 372475.1200
D 24 30.750000 1137.7500 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
4954 8396.000000 292625.9900 0.0000
Other 49 87.250000 5564.8900 2290.8600
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Total 14622 207432.500000 1088309.5300 735827.0300