CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 59 73.000000 71.4400 0.9786
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 4.000000 148.0000 37.0000
Subtotal (Total Children Is Unduplicated) 63 77.000000 219.4400 2.8499
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 9.000000 675.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 5.500000 412.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 9.500000 527.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 2.000000 100.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 21 103.000000 5150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 34 139.000000 7614.7500 54.7824
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 35 47.250000 2362.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 8 8.750000 218.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 19 39.500000 1975.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 4 4.000000 200.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 16 25.250000 1262.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 5 7.000000 175.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 28 37.000000 1850.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 163 755.000000 37750.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 18 118.000000 8360.3400 70.8503
PHY-97110-PT SESSION BY LICENSED PT 36 152.000000 10665.5600 70.1682
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 155 799.000000 56908.9600 71.2252
TRAV-TRAVS-Travel by mile 679 43308.00000 19175.9100 0.4428
Subtotal (Total Children Is Unduplicated) 733 45301.75000 140929.5200 3.1109
-----------------------------------------------------------------------------------------------------------------------
Total 45517.750000 148763.7100 3.2683
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 788
-----------------------------------------------------------------------------------------------------------------------
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 2285 45505.250000 148101.3900 148101.3900
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 1 0.750000 27.7500 27.7500
11 11.750000 634.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2297 45517.750000 148763.7100 148129.1400