CMS/EIP Fiscal Report Center: 05
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 306 168.250000 6225.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 273 258.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 762 2261.250000 83666.2500 37.0000
Subtotal (Total Children Is Unduplicated) 764 2687.750000 89891.5000 33.4449
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 47 69.500000 3475.0000 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 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 55 91.000000 6825.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 42 48.500000 3637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 17.000000 943.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 81 115.500000 8662.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 6.000000 306.3000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 8.000000 329.1800 41.1475
Subtotal (Total Children Is Unduplicated) 162 368.000000 24946.2800 67.7888
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 83 91.000000 4550.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 2.250000 56.2500 25.0000
CONIF-CONIF-CONSULT, FACE TO FACE 101 130.250000 6512.5000 50.0000
CONIP-CONIP-CONSULT, PHONE 7 5.750000 143.7500 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 9 49.250000 1231.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 184 1075.000000 53750.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 161 564.000000 5640.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 68.250000 4203.5700 61.5908
PHY-97110-PT SESSION BY LICENSED PT 25 79.500000 3418.4000 42.9987
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 62 263.000000 17697.4800 67.2908
TRAV-TRAVS-Travel by mile 474 49108.00000 21855.9850 0.4451
Subtotal (Total Children Is Unduplicated) 501 51436.25000 119059.1850 2.3147
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Total 54492.000000 233896.9650 4.2923
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Number of Children (Unduplicated) With at Least One Service 778
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Center 05
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 2552 1632.250000 67555.2500 0.0000
P 3071 50894.750000 121732.9000 102853.8800
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 0 0.000000 0.0000 0.0000
2599 1965.000000 44608.8150 37.7400
Other 0 0.000000 0.0000 0.0000
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Total 8222 54492.000000 233896.9650 102891.6200