CMS/EIP Fiscal Report Center: 57
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 236 103.250000 3820.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 91 61.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1475 5229.000000 193473.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1478 5393.250000 197293.2500 36.5815
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 1.000000 50.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 98 178.000000 8900.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 7.000000 525.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 9.500000 527.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 232 217.000000 16275.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 7.000000 525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 296 315.000000 17482.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 119 138.000000 10350.0000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 4.000000 204.2000 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 25 25.000000 1276.2500 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.000000 255.2500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 19 19.000000 969.9500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 73 75.000000 3828.7500 51.0500
Subtotal (Total Children Is Unduplicated) 536 1004.000000 61431.6500 61.1869
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.500000 75.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 41 41.000000 2050.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 14 14.000000 700.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 143 145.000000 7250.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 13 311.000000 7775.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 927 6049.000000 302450.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1034 7130.000000 71300.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 149 543.250000 38809.7800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 70 173.500000 9924.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 74 224.250000 16020.4200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 75 293.250000 16762.1700 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 172 648.750000 46346.7000 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 107 289.000000 16530.8000 57.2000
TRAV-TRAVS-Travel by mile 52 12606.00000 5609.8800 0.4450
Subtotal (Total Children Is Unduplicated) 1283 28469.50000 541603.9500 19.0240
-----------------------------------------------------------------------------------------------------------------------
Total 34866.750000 800328.8500 22.9539
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1786
-----------------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 3.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2644 2529.500000 104101.2500 0.0000
P 946 976.905100 36281.0500 35936.8000
D 11 16.000000 592.0000 0.0000
S 157 352.750000 10306.7600 10306.7200
H 0 0.000000 0.0000 0.0000
T 3259 22382.344900 234989.7400 234989.7400
4961 8544.250000 412266.9600 307278.8000
Other 39 62.000000 1680.0900 1652.3400
---------------------------------------------------------
Total 12020 34866.750000 800328.8500 590164.4000