CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 Page: 1
List order: No List
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 857 1056.000000 39072.0000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 373 373.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 14 10.750000 397.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1529 5638.750000 208534.0000 36.9823
Subtotal (Total Children Is Unduplicated) 1585 7078.500000 248003.7500 35.0362
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 61 60.500000 3025.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 99 89.500000 4475.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 2.500000 187.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 30 28.000000 2100.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 30 29.000000 1609.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 53 34.500000 2587.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 9.500000 712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 86 58.500000 4387.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 219 202.500000 11238.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 153 150.500000 11287.5000 75.0000
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.000000 54.4400 27.2200
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 115 115.000000 11164.5200 97.0828
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.000000 591.8100 147.9525
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 5 5.000000 115.6900 23.1380
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 34 34.000000 2125.0300 62.5009
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.000000 145.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 58 58.000000 2813.0000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 9 9.000000 436.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 31 31.000000 1503.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 40 45.000000 2182.5000 48.5000
Subtotal (Total Children Is Unduplicated) 541 977.000000 63193.2400 64.6809
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 30 63.750000 3187.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 10 10.000000 500.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 11 11.000000 550.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 103 3593.000000 89825.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1022 9433.250000 471462.5000 49.9788
OCCT-97530-OT SESSION BY LICENSED OT 167 1091.750000 74107.9900 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 36 226.500000 12303.4800 54.3200
PHY-97110-PT SESSION BY LICENSED PT 131 560.250000 38029.7700 67.8800
PHY-97110HM-PT SESSION BY PT ASST 29 145.000000 7876.4000 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 132 642.000000 43578.9600 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 24.500000 1330.8400 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 17 14.500000 191.4000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 365 377.000000 3016.0000 8.0000
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 1037 10158.00000 101570.0000 9.9990
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 9 32.000000 16.0000 0.5000
Subtotal (Total Children Is Unduplicated) 1313 26383.50000 847595.8400 32.1260
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Total 34439.000000 1158792.8300 33.6477
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Number of Children (Unduplicated) With at Least One Service 1765
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Center 04
Flag Claims Units Chgs Paid
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R 22 20.500000 1328.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1679 2059.000000 78403.7500 0.0000
P 6009 15400.250000 359356.1600 333006.0200
D 61 71.000000 2627.0000 0.0000
S 2 1.250000 46.2500 0.0000
H 2464 8200.250000 414729.2000 297901.2000
T 0 0.000000 0.0000 0.0000
5082 8434.000000 286783.9800 0.0000
Other 104 252.750000 15517.9900 9822.1400
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Total 15423 34439.000000 1158792.8300 640729.3600