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:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 43 48.750000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 43 48.750000 0.0000 0.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 9.000000 675.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 6.000000 450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.000000 222.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 11.000000 825.0000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 4 35.000000 1750.0000 50.0000
Subtotal (Total Children Is Unduplicated) 17 72.500000 4445.5000 61.3172
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 20 26.000000 1300.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 5 4.500000 112.5000 25.0000
CONIF-CONIF-CONSULT, FACE TO FACE 72 88.250000 4412.5000 50.0000
CONIP-CONIP-CONSULT, PHONE 13 22.000000 550.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 111 419.000000 20950.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 62.000000 4429.2800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 35 159.000000 11358.9600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 86 402.250000 28736.7400 71.4400
TRAV-TRAVS-Travel by mile 545 28296.00000 12392.0100 0.4379
Subtotal (Total Children Is Unduplicated) 591 29479.00000 84241.9900 2.8577
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Total 29600.250000 88687.4900 2.9962
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Number of Children (Unduplicated) With at Least One Service 630
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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 1390 27146.000000 71677.2000 71677.2000
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 1.000000 50.0000 0.0000
161 2453.250000 16960.2900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1552 29600.250000 88687.4900 71677.2000