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: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 425 1357.250000 50218.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1127 2449.500000 72612.5000 29.6438
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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 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 9 6.000000 450.0000 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 25 14.000000 1050.0000 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 38 29.500000 2212.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 46 39.000000 2164.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 149 93.500000 7012.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 7 7.000000 303.7600 43.3943
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 36 36.000000 1746.0000 48.5000
Subtotal (Total Children Is Unduplicated) 475 438.000000 25618.2600 58.4892
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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
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 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) 1182 187870.0000 263061.7400 1.4002
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Total 190757.500000 361292.5000 1.8940
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Number of Children (Unduplicated) With at Least One Service 1560
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Center 04
Flag Claims Units Chgs Paid
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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 23 30.250000 1119.2500 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
3555 3198.250000 96356.5100 0.0000
Other 9 18.000000 1202.4600 339.4000
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Total 7482 190757.500000 361292.5000 260234.3500