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
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 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 718 3325.000000 123025.0000 37.0000
TCON-TCON-TRANSITION CONFERENCE 212 213.000000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 1747 8113.250000 256243.5000 31.5833
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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 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 17.000000 1275.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 10.500000 787.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 14.000000 1050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 29.500000 1637.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 14.500000 1087.5000 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 4 4.000000 194.0000 48.5000
SCREEN-T1023-SCREENING 1 3.000000 150.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.000000 97.0000 48.5000
Subtotal (Total Children Is Unduplicated) 143 283.250000 15860.0000 55.9929
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 188 247.750000 12387.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 40 22.250000 556.2500 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 141 129.750000 6487.5000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 64 53.750000 2687.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 67 60.750000 3037.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 110 107.750000 5387.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 5 2.500000 62.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 284 1860.000000 93000.0000 50.0000
INTR-INTR-INTERPRETER 207 463.500000 23025.0000 49.6764
OCCT-97530-OT SESSION BY LICENSED OT 121 870.000000 58008.1500 66.6760
PHY-97110-PT SESSION BY LICENSED PT 138 844.000000 54718.4100 64.8322
PHY-97110HM-PT SESSION BY PT ASST 4 15.000000 729.8000 48.6533
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 348 2537.000000 171250.0900 67.5010
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.2000 13.2000
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 1203 193396.0000 96698.0000 0.5000
Subtotal (Total Children Is Unduplicated) 1407 200614.0000 529073.9000 2.6373
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Total 209010.500000 801177.4000 3.8332
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Number of Children (Unduplicated) With at Least One Service 1871
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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 0 0.000000 0.0000 0.0000
P 17891 208077.500000 791091.5000 791091.5000
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
132 933.000000 10085.9000 80.0000
Other 0 0.000000 0.0000 0.0000
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Total 18023 209010.500000 801177.4000 791171.5000