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
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 705 335.750000 12390.0000 36.9025
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 811 743.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 692 2195.000000 76208.0000 34.7189
Subtotal (Total Children Is Unduplicated) 1556 3274.500000 88598.0000 27.0570
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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-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 193.2500 55.2143
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 21.500000 1416.7500 65.8953
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 9.500000 712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.000000 525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 40.500000 2164.5000 53.4444
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 9.000000 675.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 73 170.000000 9686.5500 56.9797
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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 33 43.000000 1700.0000 39.5349
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 112 359.500000 14055.0000 39.0960
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 21 91.500000 4262.4800 46.5845
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 18 74.500000 5177.4300 69.4957
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 43 226.000000 12229.9000 54.1146
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) 738 5074.000000 68091.6700 13.4197
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Total 8518.500000 166376.2200 19.5312
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Number of Children (Unduplicated) With at Least One Service 1812
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Center 01
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 40 88.000000 1134.9800 1134.9800
D 3 4.000000 210.0000 0.0000
S 127 129.250000 4526.0900 0.0000
H 0 0.000000 0.0000 0.0000
T 117 148.000000 2427.1800 2307.1800
5005 3289.750000 89123.3000 0.0000
Other 2908 4859.500000 68954.6700 0.0000
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Total 8200 8518.500000 166376.2200 3442.1600