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
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 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 435 1440.000000 53280.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1163 2879.750000 92749.7500 32.2076
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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 3 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 9.000000 499.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 9.500000 712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 25 20.500000 1537.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 40 39.000000 2164.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 18.000000 1350.0000 75.0000
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.000000 54.4400 27.2200
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 84 84.000000 3402.0000 40.5000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.000000 171.8100 57.2700
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 2 2.000000 36.3400 18.1700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 15 15.000000 332.1000 22.1400
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 48.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 36 36.000000 1746.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.000000 339.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 23 27.000000 1309.5000 48.5000
Subtotal (Total Children Is Unduplicated) 386 429.500000 21691.6900 50.5045
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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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 195 1643.000000 82150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 87 597.000000 40524.3600 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 24 144.000000 7822.0800 54.3200
PHY-97110-PT SESSION BY LICENSED PT 29 175.500000 11912.9400 67.8800
PHY-97110HM-PT SESSION BY PT ASST 14 53.000000 2878.9600 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 42 258.000000 17513.0400 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 24.500000 1330.8400 54.3200
TRAN-TRAN-FAMILY TRANSPORTATION 365 377.000000 3016.0000 8.0000
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 1037 10157.00000 101560.0000 9.9990
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 9 32.000000 16.0000 0.5000
Subtotal (Total Children Is Unduplicated) 1197 13546.75000 273011.7200 20.1533
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Total 16856.000000 387453.1600 22.9861
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Number of Children (Unduplicated) With at Least One Service 1599
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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 4170 13134.250000 270118.7600 243012.0500
D 61 71.000000 2627.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 19 52.000000 697.8800 681.4800
T 0 0.000000 0.0000 0.0000
3919 3551.250000 111726.4400 0.0000
Other 15 47.500000 2283.0800 2034.8300
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Total 8184 16856.000000 387453.1600 245728.3600