CMS/EIP Fiscal Report Center: 09
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 1332 2589.500000 95783.7500 36.9893
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 888 974.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 998 1011.750000 37434.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1813 8627.250000 319116.7500 36.9894
TCON-TCON-TRANSITION CONFERENCE 212 213.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 1896 13415.50000 452335.2500 33.7174
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 109 180.750000 9037.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 41 75.000000 5625.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 11.000000 825.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 35 66.000000 4950.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 18 32.000000 1776.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 245 402.500000 30187.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 166 233.000000 17475.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 139 233.500000 17512.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 280 515.000000 28582.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 218 352.500000 26437.5000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 48.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.000000 242.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 6.000000 291.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 145.5000 48.5000
SCREEN-T1023-SCREENING 1 3.000000 150.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.000000 242.5000 48.5000
Subtotal (Total Children Is Unduplicated) 667 2129.750000 143941.0000 67.5859
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 190 251.250000 12562.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 40 22.250000 556.2500 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 186 174.750000 8737.5000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 79 73.000000 3650.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 85 79.250000 3962.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 150 155.000000 7750.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 5 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 814 5610.000000 280500.0000 50.0000
INTR-INTR-INTERPRETER 207 463.500000 23025.0000 49.6764
OCCT-97530-OT SESSION BY LICENSED OT 171 1257.500000 84311.6500 67.0470
PHY-97110-PT SESSION BY LICENSED PT 271 1832.000000 121783.8500 66.4759
PHY-97110HM-PT SESSION BY PT ASST 20 116.000000 6216.1200 53.5872
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.000000 1000.0000 500.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 501 3633.250000 245663.5400 67.6154
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.000000 26.4000 13.2000
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 1324 272916.0000 136458.0000 0.5000
Subtotal (Total Children Is Unduplicated) 1486 286592.7500 936328.3100 3.2671
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Total 302138.000000 1532604.5600 5.0725
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Number of Children (Unduplicated) With at Least One Service 1940
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Center 09
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 6926 6704.250000 292948.6500 55.5000
P 19574 285264.500000 844301.8700 844355.1200
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 0 0.000000 0.0000 0.0000
2703 10169.250000 395354.0400 80.0000
Other 0 0.000000 0.0000 0.0000
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Total 29203 302138.000000 1532604.5600 844490.6200