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
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 266 133.500000 4939.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 88 67.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 540 1869.500000 69171.5000 37.0000
Subtotal (Total Children Is Unduplicated) 754 2070.000000 74111.0000 35.8024
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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 2 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 102 99.500000 7462.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 100 105.000000 5827.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 45.000000 3375.0000 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 55 55.000000 2806.7000 51.0309
Subtotal (Total Children Is Unduplicated) 286 514.500000 30161.8500 58.6236
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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 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 942 7789.000000 77890.0000 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 45 14178.00000 6309.4500 0.4450
Subtotal (Total Children Is Unduplicated) 1007 24796.75000 246800.6900 9.9529
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Total 27381.250000 351073.5400 12.8217
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Number of Children (Unduplicated) With at Least One Service 1338
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Center 57
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 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 3514 24330.250000 242974.8700 244085.6800
2785 2488.000000 99050.5600 1471.5600
Other 2 6.000000 244.3200 244.3200
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Total 6467 27381.250000 351073.5400 254615.3500