CMS/EIP Fiscal Report Center: 06
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 1425 1611.500000 59625.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 698 565.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1547 3928.750000 145419.2500 37.0141
Subtotal (Total Children Is Unduplicated) 1655 6105.250000 205044.7500 33.5850
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 10 16.750000 837.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 9.500000 712.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 12.500000 693.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 210 301.500000 22612.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 130 193.500000 14512.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 168 245.000000 13597.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 61.500000 4612.5000 75.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.000000 229.0800 57.2700
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 2.000000 41.0500 20.5250
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 3.000000 151.0500 50.3500
Subtotal (Total Children Is Unduplicated) 298 855.250000 58449.9300 68.3425
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 1481.7500 1481.7500
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 87 87.000000 4037.5000 46.4080
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 6 4.000000 100.0000 25.0000
CONIF-CONIF-CONSULT, FACE TO FACE 32 82.500000 3962.5000 48.0303
CONIP-CONIP-CONSULT, PHONE 19 34.750000 793.7500 22.8417
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 187 1393.250000 69325.0000 49.7578
INTR-T1013-INTERPRETER 30 134.000000 8704.0000 64.9552
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 829 6689.000000 66670.0000 9.9671
OCCT-97530-OT SESSION BY LICENSED OT 28 98.500000 6224.8900 63.1969
OCCT-97530HM-OT SESSION BY OT ASST 3 4.000000 228.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 40 175.750000 11631.4900 66.1820
PHY-97110HM-PT SESSION BY PT ASST 9 24.750000 1149.8900 46.4602
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 117 511.500000 35435.0600 69.2768
SPL-92508-GROUP SPL SESSION PER CHILD 2 4.000000 52.8000 13.2000
Subtotal (Total Children Is Unduplicated) 860 9244.000000 209797.4300 22.6955
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Total 16204.500000 473292.1100 29.2074
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Number of Children (Unduplicated) With at Least One Service 1749
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Center 06
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 9249 8745.750000 200036.2300 200036.2300
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
12408 7458.750000 273255.8800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 21657 16204.500000 473292.1100 200036.2300