CMS/EIP Fiscal Report Center: 09
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 1712 4963.000000 183575.5000 36.9888
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 920 1008.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1684 5773.000000 213490.0000 36.9808
Subtotal (Total Children Is Unduplicated) 1888 11744.25000 397065.5000 33.8094
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 96 191.750000 9387.5000 48.9570
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 24.000000 1800.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 12.000000 900.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 14.500000 804.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 282 427.500000 31376.0000 73.3942
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 147 190.500000 14023.5700 73.6145
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 127 180.500000 13391.2500 74.1898
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 266 423.000000 23448.7500 55.4344
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 209 274.000000 20550.0000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 13 68.000000 3400.0000 50.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 8 8.000000 408.4000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 617 1819.250000 119854.8200 65.8814
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 149 277.750000 12202.1900 43.9323
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 18 17.000000 425.0000 25.0000
CONIF-CONIF-CONSULT, FACE TO FACE 210 437.500000 21875.0000 50.0000
CONIP-CONIP-CONSULT, PHONE 30 81.500000 2037.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 916 6304.500000 315025.0000 49.9683
INTR-T1013-INTERPRETER 99 211.500000 10399.0000 49.1678
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1291 12288.00000 122880.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 143 1083.000000 77369.5200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 230 1719.000000 117637.4200 68.4336
PHY-97110HM-PT SESSION BY PT ASST 1 3.000000 171.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 425 3606.250000 256618.2100 71.1593
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
TRAV-TRAVS-Travel by mile 1259 126356.0000 55252.3100 0.4373
Subtotal (Total Children Is Unduplicated) 1416 152386.0000 991906.5100 6.5092
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Total 165949.500000 1508826.8300 9.0921
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Number of Children (Unduplicated) With at Least One Service 1946
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Center 09
Flag Claims Units Chgs Paid
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R 5 5.000000 198.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 190 226.500000 12625.9400 225.2500
P 26788 156669.250000 1140332.1200 1251368.8700
D 0 0.000000 0.0000 0.0000
S 1 1.250000 46.2500 46.2500
H 0 0.000000 0.0000 0.0000
T 2 3.000000 162.5000 37.5000
2476 9044.500000 355462.0200 866.1100
Other 0 0.000000 0.0000 0.0000
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Total 29462 165949.500000 1508826.8300 1252543.9800