CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2013 ending 03/31/2013 Date of Report:05/17/2013 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 787 807.750000 29886.7500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 413 413.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 14 12.250000 417.2500 34.0612
TCM-T1017TL-TARGETED CASE MANAGEMENT 565 1887.500000 69837.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1182 3120.500000 100141.5000 32.0915
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
EVAL-EVAL-DEVELOPMENTAL EVALUATION 73 69.000000 3450.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 97 85.500000 4275.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 1.000000 75.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 1.500000 112.5000 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 18 13.500000 1012.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 5.000000 277.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 10.000000 750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 30 22.500000 1687.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 33.000000 1831.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 108 66.000000 4950.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 162.0000 40.5000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 22.1400 22.1400
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 48 48.000000 2328.0000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 16 16.000000 776.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 28 29.000000 1406.5000 48.5000
Subtotal (Total Children Is Unduplicated) 426 408.500000 23325.6400 57.1007
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 23 38.750000 1937.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 3 3.000000 75.0000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 2.000000 100.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 5 5.000000 250.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 12 12.000000 600.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 189 1605.000000 80250.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 116 871.000000 59123.4800 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 1 2.000000 108.6400 54.3200
PHY-97110-PT SESSION BY LICENSED PT 45 295.500000 20058.5400 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 4.500000 244.4400 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 47 315.000000 21382.2000 67.8800
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 381 390.000000 3120.0000 8.0000
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 1038 195420.0000 97710.0000 0.5000
Subtotal (Total Children Is Unduplicated) 1169 198998.7500 286819.8800 1.4413
-----------------------------------------------------------------------------------------------------------------------
Total 202527.750000 410287.0200 2.0258
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1556
-----------------------------------------------------------------------------------------------------------------------
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 4125 198163.750000 280234.9800 277989.4300
D 35 39.000000 1443.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 102.500000 201.8200 191.8200
T 0 0.000000 0.0000 0.0000
4351 3790.000000 120779.1400 0.0000
Other 53 432.500000 7628.0800 7356.5600
---------------------------------------------------------
Total 8568 202527.750000 410287.0200 285537.8100