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
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 266 133.500000 4939.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 88 67.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1376 4968.250000 183825.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1384 5168.750000 188764.7500 36.5204
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 88 149.000000 7450.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 253 244.500000 18337.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 16.000000 1200.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 260 271.000000 15040.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 122 140.500000 10537.5000 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 51 51.000000 2603.5500 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 6.000000 306.3000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 17 17.000000 867.8500 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 83 85.000000 4338.2000 51.0376
Subtotal (Total Children Is Unduplicated) 522 1003.000000 62128.1000 61.9423
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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 197 210.500000 10525.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 20 938.000000 23450.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 765 6238.000000 311900.0000 50.0000
INTR-T1013-INTERPRETER 1 3.000000 225.0000 75.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 948 7842.000000 78420.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 127 472.250000 33737.5400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 78 254.500000 14557.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 106 487.000000 34791.2800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 70 316.000000 18062.5600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 225 1175.500000 83977.7200 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 98 392.000000 22422.4000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 2 6.000000 83.2800 13.8800
TRAV-TRAVS-Travel by mile 45 14178.00000 6309.4500 0.4450
Subtotal (Total Children Is Unduplicated) 1196 32521.75000 638911.6300 19.6457
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Total 38693.500000 889804.4800 22.9962
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Number of Children (Unduplicated) With at Least One Service 1633
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Center 57
Flag Claims Units Chgs Paid
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R 6 6.750000 249.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3493 3410.250000 136462.2500 0.0000
P 1 1.500000 55.5000 55.5000
D 8 7.750000 343.2500 0.0000
S 167 560.500000 9053.8300 9063.8300
H 15 18.500000 1023.5000 0.0000
T 3520 24338.250000 243460.6300 244571.4400
5397 10243.000000 495293.5000 393528.0000
Other 71 107.000000 3862.2700 3923.7100
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Total 12678 38693.500000 889804.4800 651142.4800