CMS/EIP Fiscal Report Center: 55
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 920 1154.250000 42707.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 192 179.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 959 2721.250000 100686.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1107 4054.750000 143393.5000 35.3643
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 3 3.500000 175.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 5 6.000000 300.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 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 118 233.729403 17529.6302 74.9997
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 30 59.000400 4425.0000 74.9995
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 87 173.000000 12975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 44 86.500000 4800.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 46 92.000000 6900.0000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 51.0500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.000000 204.2000 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.000000 102.1000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.000000 306.3000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 11.000000 561.5500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 227 684.729803 48831.6302 71.3152
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 4.000000 1820.8700 455.2175
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 3.500000 175.0000 50.0000
CONIF-CONIF-CONSULT, FACE TO FACE 2 4.000000 200.0000 50.0000
CONIP-CONIP-CONSULT, PHONE 20 40.250000 1006.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 102 570.500000 28525.0000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 114.0000 57.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 546 4671.000000 46710.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 131 739.500600 52830.8800 71.4413
OCCT-97530HM-OT SESSION BY OT ASST 43 215.000400 12298.0000 57.1999
PHY-97110-PT SESSION BY LICENSED PT 126 676.500671 48329.1658 71.4399
PHY-97110HM-PT SESSION BY PT ASST 30 122.000000 6973.5200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 380 2256.752300 161222.2196 71.4399
TRAV-TRAVS-Travel by mile 71 3570.000000 1589.1900 0.4452
Subtotal (Total Children Is Unduplicated) 594 12875.00397 361794.0954 28.1005
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Total 17614.483774 554019.2256 31.4525
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Number of Children (Unduplicated) With at Least One Service 1158
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Center 55
Flag Claims Units Chgs Paid
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R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 171 162.750000 6021.7500 18.5000
P 9583 12360.217249 274125.6202 292024.1500
D 44 43.000000 1591.0000 0.0000
S 54 31.000000 1147.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6716 5016.516525 271096.8554 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 16569 17614.483774 554019.2256 292042.6500