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
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 873 908.250000 33605.2500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 511 511.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 14 12.250000 417.2500 34.0612
TCM-T1017TL-TARGETED CASE MANAGEMENT 1637 6080.000000 224960.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1700 7511.500000 258982.5000 34.4781
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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 76 71.000000 3550.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 97 85.500000 4275.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 5.000000 375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 21 13.000000 975.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 25 22.500000 1687.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 49 46.000000 2553.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 68 37.500000 2812.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 6.500000 487.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 146 92.500000 6937.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 359 313.000000 17371.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 185 135.000000 10125.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 184 184.000000 18210.7000 98.9712
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 22 22.000000 853.3400 38.7882
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 19 20.000000 970.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 70 70.000000 3395.0000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 8 8.000000 388.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 34 34.000000 1649.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 64 66.000000 3201.0000 48.5000
Subtotal (Total Children Is Unduplicated) 701 1236.500000 80165.0400 64.8322
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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
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 3 272.000000 6800.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 73 2202.000000 55050.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1022 9098.000000 454900.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 183 1227.000000 83288.7600 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 2 5.000000 271.6000 54.3200
PHY-97110-PT SESSION BY LICENSED PT 137 677.500000 45988.7000 67.8800
PHY-97110HM-PT SESSION BY PT ASST 2 8.500000 461.7200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 121 610.250000 41423.7700 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 37.000000 2009.8400 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 3 2.000000 26.4000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 456 470.000000 3760.0000 8.0000
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 1040 195820.0000 97910.0000 0.5000
Subtotal (Total Children Is Unduplicated) 1336 210490.0000 794853.2900 3.7762
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Total 219238.000000 1134000.8300 5.1725
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Number of Children (Unduplicated) With at Least One Service 1884
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Center 04
Flag Claims Units Chgs Paid
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R 124 71.750000 2654.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2004 2094.250000 80461.0000 0.0000
P 5714 200582.000000 362076.5000 359623.9900
D 37 40.750000 1526.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 2334 7602.000000 379741.8600 348743.9200
T 0 0.000000 0.0000 0.0000
6140 8293.000000 292167.1000 0.0000
Other 115 554.250000 15372.8700 15018.1000
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Total 16468 219238.000000 1134000.8300 723386.0100