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
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 718 863.500000 31949.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 378 526.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 178 371.000000 13727.0000 37.0000
Subtotal (Total Children Is Unduplicated) 769 1760.500000 45676.5000 25.9452
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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 1 2.000000 111.0000 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 42 80.000000 4440.0000 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) 83 219.500000 13598.6900 61.9530
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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 1 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 77 476.000000 23800.0000 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 14 74.000000 5286.5600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 29 200.000000 11718.0800 58.5904
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 82 686.500000 48792.0400 71.0736
TRAV-TRAVS-Travel by mile 234 15938.00000 7067.9900 0.4435
Subtotal (Total Children Is Unduplicated) 538 19992.75000 133602.9600 6.6826
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Total 21972.750000 192878.1500 8.7781
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Number of Children (Unduplicated) With at Least One Service 890
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Center 02
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 1 1.000000 10.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3763 12655.250000 115013.0000 84777.8900
429 448.750000 14832.5200 121.4400
Other 3572 8867.750000 63022.6300 40.0000
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Total 7765 21972.750000 192878.1500 84939.3300