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
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 738 327.750000 12119.5000 36.9779
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 954 932.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 812 2275.500000 84177.0000 36.9927
Subtotal (Total Children Is Unduplicated) 1750 3536.000000 96296.5000 27.2332
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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 7 12.500000 937.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.500000 402.5000 73.1818
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 59 98.500000 6499.1000 65.9807
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 14.500000 1087.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 13.000000 975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 88 139.000000 7631.2500 54.9011
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 39.000000 2721.4200 69.7800
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 102.1000 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 11.000000 516.5000 46.9545
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 263 559.500000 32152.8200 57.4671
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 130 159.500000 7962.5000 49.9216
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 297 1760.500000 87058.0900 49.4508
INTR-T1013-INTERPRETER 194 499.500000 24837.5000 49.7247
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1206 9006.000000 89445.2100 9.9317
OCCT-97530-OT SESSION BY LICENSED OT 26 176.750000 12289.7100 69.5316
OCCT-97530HM-OT SESSION BY OT ASST 1 4.000000 228.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 43 225.500000 13383.2200 59.3491
PHY-97110HM-PT SESSION BY PT ASST 3 7.000000 400.1200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 101 604.250000 41673.9300 68.9680
SPL-92508-GROUP SPL SESSION PER CHILD 3 4.000000 55.5200 13.8800
TRAV-TRAVS-Travel by mile 766 66392.00000 27978.7700 0.4214
Subtotal (Total Children Is Unduplicated) 1410 79077.75000 317150.8700 4.0106
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Total 83173.250000 445600.1900 5.3575
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Number of Children (Unduplicated) With at Least One Service 2264
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Center 01
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 16015 71683.000000 292593.5200 292593.5200
D 617 3142.250000 20260.5700 10.0000
S 102 110.250000 5573.2200 112.5000
H 0 0.000000 0.0000 0.0000
T 671 3674.000000 9727.9800 9727.9500
5977 4563.750000 117444.9000 50.0000
Other 0 0.000000 0.0000 0.0000
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Total 23382 83173.250000 445600.1900 302493.9700