CMS/EIP Fiscal Report Center: 03
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 788 397.500000 14707.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 403 1169.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 547 1028.500000 38054.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1223 2595.750000 52762.0000 20.3263
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 8 10.000000 485.0000 48.5000
EVAL-96111-DEVELOPMENTAL EVALUATION 58 102.000000 5100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 28 39.750000 1987.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 85 138.500000 10348.5000 74.7184
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 29 44.500000 3337.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 38 53.500000 4012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 65 98.000000 5378.0000 54.8776
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 15.000000 1125.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 102.1000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 225 511.250000 32332.4000 63.2419
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.000000 115.8800 57.9400
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 138 135.750000 6787.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 6 4.250000 106.2500 25.0000
CONIF-CONIF-CONSULT, FACE TO FACE 330 915.000000 45750.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 132 413.250000 20662.5000 50.0000
INTR-T1013-INTERPRETER 10 72.000000 2981.3200 41.4072
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 498 2500.000000 24831.0000 9.9324
OCCT-97530-OT SESSION BY LICENSED OT 27 116.500000 8132.8500 69.8099
PHY-97110-PT SESSION BY LICENSED PT 23 85.750000 5719.8600 66.7039
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 54 207.500000 14223.5300 68.5471
TRAV-TRAVS-Travel by mile 434 33664.00000 14985.1400 0.4451
Subtotal (Total Children Is Unduplicated) 604 38116.00000 144295.8300 3.7857
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Total 41223.000000 229390.2300 5.5646
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Number of Children (Unduplicated) With at Least One Service 1412
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Center 03
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 1 0.250000 9.2500 9.2500
D 24 19.500000 914.4400 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
11340 41203.250000 228466.5400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11365 41223.000000 229390.2300 9.2500