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
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 236 103.250000 3820.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 91 61.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 570 2075.250000 76784.2500 37.0000
Subtotal (Total Children Is Unduplicated) 740 2239.500000 80604.5000 35.9922
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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 3 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 90 84.000000 6300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 114 121.500000 6743.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 46 54.000000 4050.0000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.000000 153.1500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 14.000000 714.7000 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.000000 204.2000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 11 11.000000 561.5500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 52 54.000000 2756.7000 51.0500
Subtotal (Total Children Is Unduplicated) 295 531.000000 30862.5500 58.1216
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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 141 142.000000 7100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 305 1878.000000 93900.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1033 7088.000000 70880.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 40 204.750000 14627.3400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 8.000000 457.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 32 113.500000 8108.4400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 19 133.500000 7630.8600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 74 388.844900 27779.0800 71.4400
TRAV-TRAVS-Travel by mile 52 12606.00000 5609.8800 0.4450
Subtotal (Total Children Is Unduplicated) 1093 22619.09490 238918.2000 10.5627
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Total 25389.594900 350385.2500 13.8003
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Number of Children (Unduplicated) With at Least One Service 1431
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Center 57
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 0 0.000000 0.0000 0.0000
D 9 12.500000 462.5000 0.0000
S 157 352.750000 10306.7600 10306.7200
H 0 0.000000 0.0000 0.0000
T 3258 22384.344900 235089.7400 235089.7400
2911 2640.000000 104526.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6335 25389.594900 350385.2500 245396.4600