qUARTERLY fINANCIAL pROGrESS rEPORT

Reporting Period

/ /17 thru / /17

(Quarterly Financial Reports Due on April 10, July 10, October 10 and February 14)

Grant Organization: / Reported by:
2017 Actual for
Reporting Period / 2017 Actual
Year to Date / 2017 Annual Approved Budget
PERSONNEL EXPENSE:
Position #1 (Name & Title):
Position #2 (Name & Title): / $
$ / $
$ / $
$
SUPPLIES (List each request item with associated cost)
$
$ / $
$ / $
$
TRAVEL (Reimbursable at IRS rate of $0.54 per mile)
______Miles @ 0.54 per mile / $ / $ / $
SUB-TOTAL / $ / $ / $
Patient Care Costs: (Based on Medicare Reimbursement Rates)
Code / Service Description / # Completed / Rate
G0101 / Clinical Breast Exam / @ / $36.34 / = / $ / $ / $
77057 / Screening Mammogram (Film) / @ / $77.61 / = / $ / $ / $
77055 / Diagnostic, Unilateral (Film) / @ / $84.53 / = / $ / $ / $
77056 / Diagnostic, Bilateral (Film) / @ / $108.65 / = / $ / $ / $
G0202 / Screening Mammogram (Digital) / @ / $125.75 / = / $ / $ / $
77063 / Tomosynthesis (Screening) / @ / $52.81 / = / $ / $ / $
G0204 / Diagnostic, Bilateral (Digital) / @ / $153.83 / = / $ / $ / $
G0206 / Diagnostic, Unilateral (Digital) / @ / $120.81 / = / $ / $ / $
G0279 / Tomosynthesis (Diagnostic) / @ / $52.81 / = / $ / $ / $
76641 / Ultrasound Breast, complete / @ / $101.77 / = / $ / $ / $
76642 / Ultrasound Breast, limited / @ / $83.82 / = / $ / $ / $
19000 / Drainage of Breast Lesion / @ / $107.03 / = / $ / $ / $
19001 / Drainage of Breast Lesion (add-on) / @ / $26.04 / = / $ / $ / $
10021 / Fine Needle Aspiration w/o guidance / @ / $116.83 / = / $ / $ / $
10022 / Fine Needle Aspiration w/guidance / @ / $134.08 / = / $ / $ / $
19081 / Biopsy – Stereotactic / @ / $654.68 / = / $ / $ / $
19083 / Biopsy – Ultrasound / @ / $633.26 / = / $ / $ / $
88305 / Tissue Exam by Pathologist / @ / $70.05 / = / $ / $ / $
77058 / MRI, Unilateral / @ / $502.56 / = / $ / $ / $
77059 / MRI, Bilateral / @ / $499.92 / = / $ / $ / $
78800 / MBI – Tumor imaging limited area / @ / $184.56 / = / $ / $ / $
78801 / MBI – Tumor imaging multi-area / @ / $251.76 / = / $ / $ / $
Other – Preapproved Procedure (specify): / @ / = / $ / $ / $
Other – Preapproved Procedure (specify): / @ / = / $ / $ / $
SUB-TOTAL – Patient Costs / $ / $ / $
GRAND TOTALS / $ / $ / $

Signature of Reporting Personnel:______Date:______

Signature of Project Director:______Date:______

Patient summary form
# / First
Date of Service / Patient
DOB/Age / Initial
Procedure(s) Provided* / Follow-up Procedure(s)* and
Service Date(s) / Insured or
Uninsured
(Enter I or U below) / Annual Household Income / Number in Household
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(Add Additional Pages as Necessary)

*Procedure Codes:

Clinical Breast Exam / CBE / US – Comp or Lmtd / USC/USL / Biopsy – Stereo or US / BS/BU / MBI – lmtd/multi / MBL/MBM
Screening Mammo / S / Drainage of Lesion / DL / Pathology / P / Other: Specify
Diagnostic – Uni or Bi / DU/DB / Needle Aspiration / FNA / MRI – Uni or Bi / MRU/MRB / Other: Specify

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