CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 Page: 1
List order: No List
Payclass Filters:OTHER
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 33 11.750000 434.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 97 263.500000 9435.0000 35.8065
Subtotal (Total Children Is Unduplicated) 98 275.250000 9869.7500 35.8574
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Screening, Eval, and Assessment,Class #02
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 2 3.000000 265.0000 88.3333
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 3.500000 175.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 53 45.000000 2250.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 20 20.250000 1012.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 21 18.500000 925.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 57 48.250000 2412.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 0.500000 12.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 25.000000 1250.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 67.8800 67.8800
PHY-97110-PT SESSION BY LICENSED PT 2 2.500000 169.7000 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.000000 203.6400 67.8800
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 18 85.000000 850.0000 10.0000
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 953 79520.00000 39760.0000 0.5000
Subtotal (Total Children Is Unduplicated) 980 79773.50000 49113.7200 0.6157
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Total 80051.750000 59248.4700 0.7401
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Number of Children (Unduplicated) With at Least One Service 1077
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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 1575 77027.000000 44911.0000 44911.0000
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 0 0.000000 0.0000 0.0000
67 2653.000000 2486.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1642 79680.000000 47397.5000 44911.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 0 0.000000 0.0000 0.0000
299 250.250000 8944.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 299 250.250000 8944.7500 0.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 0 0.000000 0.0000 0.0000
1 2.000000 150.0000 0.0000
Other 41 119.500000 2756.2200 2756.2200
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Total 42 121.500000 2906.2200 2756.2200