CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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 738 327.750000 12119.5000 36.9779
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 954 932.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2502 7339.000000 271402.0000 36.9808
Subtotal (Total Children Is Unduplicated) 2543 8599.500000 283521.5000 32.9695
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 15 16.000000 776.0000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 103 198.000000 9900.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 32.500000 2437.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 16 27.000000 2015.0000 74.6296
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 15.000000 832.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 159 248.500000 17749.1000 71.4249
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 58 80.500000 6037.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 59 94.000000 7050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 174 268.000000 14790.7500 55.1894
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 105 168.000000 12396.4200 73.7882
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.000000 204.2000 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 51.0500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 12.000000 567.5500 47.2958
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 496 1178.000000 75676.3700 64.2414
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 132 161.500000 8062.5000 49.9226
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.500000 37.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 74 151.000000 7550.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 3 2.500000 62.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 7 8.000000 400.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 17 21.000000 1050.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 37 54.750000 2737.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 350 1996.250000 98845.5900 49.5156
INTR-T1013-INTERPRETER 194 499.500000 24837.5000 49.7247
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1206 9007.000000 89455.2100 9.9317
OCCT-97530-OT SESSION BY LICENSED OT 36 211.750000 14790.1100 69.8470
OCCT-97530HM-OT SESSION BY OT ASST 1 4.000000 228.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 77 349.500000 22221.3900 63.5805
PHY-97110HM-PT SESSION BY PT ASST 5 11.000000 628.7600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 135 733.500000 50848.1100 69.3226
SPL-92508-GROUP SPL SESSION PER CHILD 3 4.000000 55.5200 13.8800
TRAV-TRAVS-Travel by mile 767 66425.00000 27993.4600 0.4214
Subtotal (Total Children Is Unduplicated) 1466 79641.75000 349804.4500 4.3922
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Total 89419.250000 709002.3200 7.9290
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Number of Children (Unduplicated) With at Least One Service 2655
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Center 01
Flag Claims Units Chgs Paid
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R 47 22.250000 823.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 7156 4688.000000 173690.0000 0.0000
P 16058 71727.250000 295135.2400 295135.2400
D 917 3529.250000 46080.1500 10.0000
S 1070 1113.750000 61531.5900 112.5000
H 30 39.500000 2944.7000 0.0000
T 677 3713.000000 10123.4900 10123.4600
6008 4586.250000 118673.9000 50.0000
Other 0 0.000000 0.0000 0.0000
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Total 31963 89419.250000 709002.3200 305431.2000