CMS/EIP Fiscal Report Center: 55
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 854 875.250000 32384.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 265 218.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1096 3566.750000 131960.5000 36.9974
Subtotal (Total Children Is Unduplicated) 1128 4660.000000 164344.7500 35.2671
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 6 12.750000 637.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 6 8.000000 400.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 18.666667 1400.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 9.000000 675.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 219 436.833433 32762.5003 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 74 148.000100 11100.0000 74.9999
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 82 162.500000 12187.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 33 66.000000 3663.0000 55.5000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.000000 153.1500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 18 18.000000 918.9000 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 51.0500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.000100 306.3000 51.0491
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 288 901.750300 64981.1003 72.0611
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 130.2000 65.1000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 1.750000 87.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 5 5.000000 125.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 45 43.000000 2150.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 44 50.500000 1262.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 6 7.000000 350.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 18 22.000000 550.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 41 39.500000 1975.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 18 20.500000 512.5000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 36.000000 900.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 309 1835.000000 91750.0000 50.0000
INTR-T1013-INTERPRETER 3 10.000000 435.4200 43.5420
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 629 5381.000000 53810.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 129 675.894598 48285.7600 71.4398
OCCT-97530HM-OT SESSION BY OT ASST 112 646.250000 36965.5000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 99 538.997199 38532.8807 71.4899
PHY-97110HM-PT SESSION BY PT ASST 52 292.750100 16733.5900 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 297 1798.999900 128520.5600 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 2 9.000000 124.9200 13.8800
TRAV-TRAVS-Travel by mile 66 2172.000000 967.0500 0.4452
Subtotal (Total Children Is Unduplicated) 708 13588.14180 424218.3807 31.2197
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Total 19149.892097 653544.2310 34.1278
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Number of Children (Unduplicated) With at Least One Service 1146
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Center 55
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 30 25.500000 943.5000 0.0000
P 11752 13137.078942 339172.2611 339172.2600
D 22 42.750000 3177.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 16 30.990400 2324.2800 0.0000
T 0 0.000000 0.0000 0.0000
7598 5913.572755 307926.4399 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 19418 19149.892097 653544.2310 339172.2600