CMS/EIP Fiscal Report Center: 02
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 565 605.750000 22412.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 303 384.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 571 1085.250000 40145.0000 36.9915
Subtotal (Total Children Is Unduplicated) 682 2075.000000 62557.7500 30.1483
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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 38 60.250000 3012.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 54 117.000000 8700.0000 74.3590
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 30.000000 2125.0000 70.8333
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 78 148.500000 8241.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 29.000000 2175.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 153.1500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 102.1000 51.0500
SCREEN-T1023-SCREENING 7 7.000000 350.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 141 406.750000 25511.1500 62.7195
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 9.000000 11558.3500 1284.2611
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 24 36.750000 1725.0000 46.9388
CONIF-CONIF-CONSULT, FACE TO FACE 43 55.000000 2675.0000 48.6364
CONIP-CONIP-CONSULT, PHONE 1 5.750000 143.7500 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 12.000000 300.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 110 526.750000 26337.5000 50.0000
INTR-T1013-INTERPRETER 11 49.500000 2460.0000 49.6970
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 356 2424.000000 23650.0000 9.7566
OCCT-97530-OT SESSION BY LICENSED OT 19 102.750000 7282.4100 70.8750
PHY-97110-PT SESSION BY LICENSED PT 12 94.000000 3663.1900 38.9701
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 94 724.750000 50848.1800 70.1596
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
TRAV-TRAVS-Travel by mile 240 17991.00000 7759.6300 0.4313
Subtotal (Total Children Is Unduplicated) 503 22032.25000 138416.8900 6.2825
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Total 24514.000000 226485.7900 9.2390
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Number of Children (Unduplicated) With at Least One Service 782
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Center 02
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 1133 4623.500000 37023.2500 5162.4350
2740 11803.250000 100110.0200 30.0000
Other 4071 8087.250000 89352.5200 0.0000
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Total 7944 24514.000000 226485.7900 5192.4350