CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.250000 9.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 17 21.500000 795.5000 37.0000
Subtotal (Total Children Is Unduplicated) 18 21.750000 804.7500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.000000 102.1000 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 34 34.000000 1735.7000 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.000000 153.1500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 12 12.000000 612.6000 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 54 54.000000 2755.6500 51.0306
Subtotal (Total Children Is Unduplicated) 93 117.000000 6081.8000 51.9812
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 9.000000 450.0000 50.0000
CONIF-CONIF-CONSULT, FACE TO FACE 184 194.500000 9725.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 213 1559.000000 77950.0000 50.0000
INTR-T1013-INTERPRETER 1 3.000000 225.0000 75.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 934 7775.000000 77750.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 25 118.000000 8429.9200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 8 36.500000 2087.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 38 234.000000 16716.9600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 10 57.500000 3286.7000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 104 605.750000 43274.7800 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 6.500000 371.8000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 2 6.000000 83.2800 13.8800
TRAV-TRAVS-Travel by mile 40 13553.00000 6031.3000 0.4450
Subtotal (Total Children Is Unduplicated) 999 24157.75000 246382.5400 10.1989
-----------------------------------------------------------------------------------------------------------------------
Total 24296.500000 253269.0900 10.4241
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1037
-----------------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 166 557.000000 8803.7900 8813.7900
H 0 0.000000 0.0000 0.0000
T 3490 23682.250000 241944.6700 243055.4800
42 51.250000 2276.3100 1471.5600
Other 2 6.000000 244.3200 244.3200
---------------------------------------------------------
Total 3700 24296.500000 253269.0900 253585.1500