CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2016 ending 03/31/2016 Date of Report:05/12/2016 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 718 863.500000 31949.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 378 526.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 703 1398.500000 51744.5000 37.0000
Subtotal (Total Children Is Unduplicated) 829 2788.000000 83694.0000 30.0194
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 27 41.000000 2050.0000 50.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 56.2500 56.2500
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 34 66.500000 4875.0000 73.3083
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 13.000000 975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 89 170.000000 9435.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 8.000000 600.0000 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 1 2.000000 102.1000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 38.2900 38.2900
Subtotal (Total Children Is Unduplicated) 132 313.500000 18815.6900 60.0182
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 9.000000 4549.1600 505.4622
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 33 32.750000 1637.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 0.750000 18.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 45 57.500000 2837.5000 49.3478
CONIP-CONIP-CONSULT, ITDS PHONE 2 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.500000 75.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 3 2.250000 112.5000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.000000 73.3200 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 5.000000 125.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 125 750.250000 37512.5000 50.0000
INTR-T1013-INTERPRETER 17 62.500000 3125.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 382 2445.000000 24373.5600 9.9687
OCCT-97530-OT SESSION BY LICENSED OT 15 92.000000 6572.4800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 31 231.000000 13807.7000 59.7736
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 86 723.500000 51435.3200 71.0924
TRAV-TRAVS-Travel by mile 234 15938.00000 7067.9900 0.4435
Subtotal (Total Children Is Unduplicated) 541 20355.00000 153384.2800 7.5355
-----------------------------------------------------------------------------------------------------------------------
Total 23456.500000 255893.9700 10.9093
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 926
-----------------------------------------------------------------------------------------------------------------------
Center 02
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 1 1.000000 10.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3787 12679.250000 116652.5400 85605.1200
509 530.750000 20183.8000 121.4400
Other 5396 10245.500000 119047.6300 40.0000
---------------------------------------------------------
Total 9693 23456.500000 255893.9700 85766.5600