CMS/EIP Fiscal Report Center: 52
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 416 211.000000 7788.5000 36.9123
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 365 428.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 291 816.500000 30155.0000 36.9320
Subtotal (Total Children Is Unduplicated) 727 1456.250000 37943.5000 26.0556
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 1.000000 26.0500 26.0500
EXIT-EXIT-EXIT ASSESSMENT 3 3.000000 150.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 214.9600 53.7400
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 21 41.000000 2360.9500 57.5841
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 10.000000 283.2100 28.3210
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 19.000000 1169.7400 61.5653
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 28.000000 1292.2800 46.1529
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.000000 357.3500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 153.1500 51.0500
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 357.3500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 60 132.000000 6879.1900 52.1151
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.000000 268.6000 134.3000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 139 179.750000 8987.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 2.750000 68.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 138 231.500000 11575.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 9 4.750000 118.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 90 136.500000 6825.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 3 1.250000 31.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 46 71.500000 3575.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 3 2.000000 50.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 96 127.750000 6387.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 62 330.000000 16500.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 660 5189.000000 51890.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 55 233.500000 16324.6800 69.9130
OCCT-97530HM-OT SESSION BY OT ASST 14 59.250000 3389.1000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 52 278.750000 19043.6600 68.3181
PHY-97110HM-PT SESSION BY PT ASST 1 10.000000 571.6000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 167 888.250000 58710.6900 66.0970
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 12.0800 12.0800
TRAV-TRAVS-Travel by mile 601 52810.00000 23504.9300 0.4451
Subtotal (Total Children Is Unduplicated) 735 60560.50000 227859.0900 3.7625
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Total 62148.750000 272681.7800 4.3876
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Number of Children (Unduplicated) With at Least One Service 937
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Center 52
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 5 17.000000 348.7500 346.2000
D 5 5.750000 389.3400 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 6435 60151.750000 225672.8000 221335.8600
3029 1974.250000 46270.8900 80.8900
Other 0 0.000000 0.0000 0.0000
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Total 9474 62148.750000 272681.7800 221762.9500