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: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 976 1191.500000 44085.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 506 506.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 14 10.750000 397.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1714 6429.000000 237773.2500 36.9845
Subtotal (Total Children Is Unduplicated) 1773 8137.250000 282256.5000 34.6870
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 62 61.500000 3075.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 99 89.500000 4475.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 5.500000 412.5000 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 7 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 32 30.000000 2250.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 36 33.500000 1859.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 81 53.500000 4012.5000 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 114 78.000000 5850.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 323 290.500000 16122.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 236 220.000000 16500.0000 75.0000
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 17 17.000000 951.0800 55.9459
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 159 159.000000 15840.7800 99.6275
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) 675 1243.500000 82499.8900 66.3449
-----------------------------------------------------------------------------------------------------------------------
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 462 479.000000 3832.0000 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) 1410 26485.50000 848411.8400 32.0331
-----------------------------------------------------------------------------------------------------------------------
Total 35866.250000 1213168.2300 33.8248
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1953
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 33 27.500000 1853.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1855 2331.250000 89373.7500 0.0000
P 6194 15654.500000 370904.9200 345060.3700
D 63 73.250000 2710.2500 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
5883 9325.500000 318032.3700 0.0000
Other 104 252.750000 15517.9900 9822.1400
---------------------------------------------------------
Total 16598 35866.250000 1213168.2300 652783.7100