CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2014 ending 03/31/2014 Date of Report:06/03/2014 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
TCM-T1017TL-TARGETED CASE MANAGEMENT 12 34.500000 1276.5000 37.0000
Subtotal (Total Children Is Unduplicated) 12 34.500000 1276.5000 37.0000
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Screening, Eval, and Assessment,Class #02
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 2 2.000000 97.0000 48.5000
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 41 38.000000 1900.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.500000 12.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 17 16.500000 825.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 4 3.500000 87.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 26 21.500000 1075.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 35 30.500000 1525.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 14 14.000000 350.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 5.000000 250.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 2.000000 135.7600 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 54.3200 54.3200
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 15 40.000000 400.0000 10.0000
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 956 86655.00000 43348.9000 0.5002
Subtotal (Total Children Is Unduplicated) 990 86827.50000 49963.9800 0.5754
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Total 86864.000000 51337.4800 0.5910
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Number of Children (Unduplicated) With at Least One Service 997
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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 1570 86395.500000 48246.5000 48246.5000
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 3 144.000000 72.0000 72.0000
46 145.500000 1332.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1619 86685.000000 49650.5000 48318.5000
Center 57
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 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 50 179.000000 1686.9800 1686.9800
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Total 50 179.000000 1686.9800 1686.9800