CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 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 705 335.750000 12390.0000 36.9025
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 811 743.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2234 6723.250000 241741.2500 35.9560
Subtotal (Total Children Is Unduplicated) 2277 7802.750000 254131.2500 32.5694
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 31 75.000000 3750.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.000000 525.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 13.500000 1012.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 11 17.500000 1312.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.000000 387.5000 55.3571
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 38 56.500000 4041.7500 71.5354
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 46 65.000000 4875.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 31 49.500000 3712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 44 68.000000 3690.7500 54.2757
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 48.500000 3637.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 207 415.000000 27433.1000 66.1039
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 1070.0000 1070.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 34 44.000000 1750.0000 39.7727
CONIF-CONIF-CONSULT, FACE TO FACE 37 55.500000 2350.0000 42.3423
CONIP-CONIP-CONSULT, PHONE 1 4.000000 25.0000 6.2500
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 123 386.500000 15405.0000 39.8577
INTR-T1013-INTERPRETER 6 78.000000 1050.0000 13.4615
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 669 2232.000000 22073.3800 9.8895
OCCT-97530-OT SESSION BY LICENSED OT 26 101.500000 4976.8800 49.0333
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 33 111.500000 7820.7100 70.1409
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 47 238.500000 13122.9000 55.0226
SPL-92508-GROUP SPL SESSION PER CHILD 8 235.000000 3261.8000 13.8800
TRAV-TRAVS-Travel by mile 57 1671.000000 743.4800 0.4449
Subtotal (Total Children Is Unduplicated) 762 5161.500000 73742.3500 14.2870
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Total 13379.250000 355306.7000 26.5565
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Number of Children (Unduplicated) With at Least One Service 2332
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Center 01
Flag Claims Units Chgs Paid
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R 8 3.000000 118.4400 0.0000
U 0 0.000000 0.0000 0.0000
B 6709 4557.000000 174415.3700 0.0000
P 41 88.250000 1144.2300 1144.2300
D 4 4.250000 219.2500 0.0000
S 296 277.250000 10348.0900 0.0000
H 34 48.500000 3605.3800 0.0000
T 117 148.000000 2427.1800 2307.1800
5107 3345.750000 91315.8400 0.0000
Other 2949 4907.250000 71712.9200 0.0000
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Total 15265 13379.250000 355306.7000 3451.4100