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
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 1712 4963.000000 183575.5000 36.9888
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 913 959.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 619 2064.250000 76340.2500 36.9821
Subtotal (Total Children Is Unduplicated) 1804 7986.750000 259915.7500 32.5434
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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 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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 67 106.000000 7461.0000 70.3868
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 31 40.500000 2773.5700 68.4832
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 30.000000 2103.7500 70.1250
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 83 136.000000 7548.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 82 110.000000 8250.0000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 9 33.000000 1650.0000 50.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 153.1500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 279 655.250000 39678.0200 60.5540
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 135 251.750000 10902.1900 43.3056
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 13 12.500000 312.5000 25.0000
CONIF-CONIF-CONSULT, FACE TO FACE 176 349.250000 17462.5000 50.0000
CONIP-CONIP-CONSULT, PHONE 29 59.500000 1487.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 251 1551.500000 77375.0000 49.8711
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 99 775.000000 55366.0000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 127 901.000000 59240.5600 65.7498
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 342 2565.000000 182231.3100 71.0453
TRAV-TRAVS-Travel by mile 1156 98060.00000 42860.3000 0.4371
Subtotal (Total Children Is Unduplicated) 1382 117025.0000 580516.8600 4.9606
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Total 125667.000000 880110.6300 7.0035
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Number of Children (Unduplicated) With at Least One Service 1902
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Center 09
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 20513 124806.250000 862176.9700 862176.4700
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 1 2.000000 112.5000 37.5000
287 858.750000 17821.1600 662.8900
Other 0 0.000000 0.0000 0.0000
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Total 20801 125667.000000 880110.6300 862876.8600