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: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 646 2199.500000 81381.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1321 3631.000000 115404.0000 31.7830
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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 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 4 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 19 14.500000 1087.5000 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 28 15.500000 1162.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 0.500000 37.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 37 26.500000 1987.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 48 39.500000 2192.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 136 81.500000 6112.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 6.000000 253.1300 42.1883
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 30 31.000000 1503.5000 48.5000
Subtotal (Total Children Is Unduplicated) 487 448.500000 26037.0200 58.0536
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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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 190 1609.000000 80450.0000 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 456 470.000000 3760.0000 8.0000
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 1040 195760.0000 97880.0000 0.5000
Subtotal (Total Children Is Unduplicated) 1245 199422.7500 287829.8800 1.4433
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Total 203502.250000 429270.9000 2.1094
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Number of Children (Unduplicated) With at Least One Service 1696
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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 4130 198507.750000 280604.9800 278359.4300
D 36 39.500000 1480.5000 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
4950 4420.000000 139355.5200 0.0000
Other 53 432.500000 7628.0800 7356.5600
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Total 9173 203502.250000 429270.9000 285907.8100