CMS/EIP Fiscal Report Center: 05
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 326 156.250000 5781.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 340 334.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 925 2502.000000 92490.7500 36.9667
Subtotal (Total Children Is Unduplicated) 928 2992.500000 98272.0000 32.8394
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 36 38.500000 1925.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 98 158.000000 11850.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 49 62.500000 4687.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 56 80.500000 4467.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 75 111.000000 8325.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.000000 189.2200 47.3050
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 132.2700 44.0900
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 211 477.000000 32889.3900 68.9505
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 83 85.750000 4287.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 0.250000 6.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 119 106.250000 5312.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 4 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 13 8.000000 400.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 3 0.750000 18.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 23 24.000000 1200.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 44 28.250000 1412.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 0.500000 12.5000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 23 115.000000 2875.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 198 1042.250000 52112.5000 50.0000
INTR-T1013-INTERPRETER 13 66.500000 3325.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 507 3032.000000 30320.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 74.000000 4474.7500 60.4696
PHY-97110-PT SESSION BY LICENSED PT 22 75.250000 4865.0800 64.6522
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 57 220.000000 14365.8400 65.2993
TRAV-TRAVS-Travel by mile 536 49780.00000 22155.5700 0.4451
Subtotal (Total Children Is Unduplicated) 587 54659.75000 147168.7400 2.6925
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Total 58129.250000 278330.1300 4.7881
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Number of Children (Unduplicated) With at Least One Service 969
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Center 05
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 2524 1708.000000 70729.7500 0.0000
P 4614 54829.250000 159577.8800 159620.3200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2691 1592.000000 48022.5000 477.7500
Other 0 0.000000 0.0000 0.0000
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Total 9829 58129.250000 278330.1300 160098.0700