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
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 565 605.750000 22412.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 303 384.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 177 349.750000 12931.5000 36.9736
Subtotal (Total Children Is Unduplicated) 628 1339.500000 35344.2500 26.3862
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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-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 46.500000 3487.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 12.000000 850.0000 70.8333
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 39 74.500000 4134.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 14.500000 1087.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 3 3.000000 150.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 93 216.750000 13073.9000 60.3179
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 7.000000 10210.4700 1458.6386
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 67 291.500000 14575.0000 50.0000
INTR-T1013-INTERPRETER 11 49.500000 2460.0000 49.6970
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 356 2419.000000 23600.0000 9.7561
OCCT-97530-OT SESSION BY LICENSED OT 18 88.750000 6282.2500 70.7859
PHY-97110-PT SESSION BY LICENSED PT 9 83.000000 3055.3700 36.8117
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 88 643.500000 45118.6900 70.1145
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) 502 21683.75000 117919.0400 5.4381
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Total 23240.000000 166337.1900 7.1574
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Number of Children (Unduplicated) With at Least One Service 757
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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 1030 4514.500000 30088.4000 5162.4350
2633 11649.500000 88180.5200 30.0000
Other 2801 7076.000000 48068.2700 0.0000
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Total 6464 23240.000000 166337.1900 5192.4350