CMS/EIP Fiscal Report Center: 02
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: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 591 522.500000 19304.7500 36.9469
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 231 245.750000 9092.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 189 266.000000 9814.2500 36.8957
Subtotal (Total Children Is Unduplicated) 615 1034.250000 38211.7500 36.9463
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 2 4.000000 200.0000 50.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 11.000000 610.5000 55.5000
Subtotal (Total Children Is Unduplicated) 9 16.000000 866.0000 54.1250
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 6.000000 334.7400 55.7900
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 5.000000 250.0000 50.0000
INTR-INTR-INTERPRETER 7 20.250000 1012.5000 50.0000
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 3 386.000000 193.0000 0.5000
Subtotal (Total Children Is Unduplicated) 12 419.250000 1890.2400 4.5086
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Total 1469.500000 40967.9900 27.8789
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Number of Children (Unduplicated) With at Least One Service 618
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Center 02
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4 6.000000 334.7400 334.7400
2062 1463.500000 40633.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2066 1469.500000 40967.9900 334.7400