CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 559 197.000000 7289.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1023 997.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2550 7015.500000 259266.7400 36.9563
Subtotal (Total Children Is Unduplicated) 2584 8209.500000 266555.7400 32.4692
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 17 17.000000 809.6300 47.6253
EXIT-EXIT-EXIT ASSESSMENT 177 352.750000 17575.0000 49.8228
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 20 29.500000 2202.5000 74.6610
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 6.500000 487.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 18 26.500000 1987.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 24.500000 1332.0000 54.3673
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 186 281.500000 20333.4900 72.2326
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 43 65.000000 4875.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 62 93.000000 6869.5100 73.8657
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 212 337.500000 18356.7400 54.3903
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 92 131.500000 9337.7400 71.0094
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 99.5500 49.7750
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 581 1380.250000 85025.6100 61.6016
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 6.000000 5339.8100 889.9683
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 187 253.500000 12350.0000 48.7179
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 87 209.000000 10450.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 15 19.500000 975.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 39 61.500000 3075.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 76 147.500000 7375.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 417 2615.250000 130654.5000 49.9587
INTR-T1013-INTERPRETER 220 645.250000 32257.5000 49.9923
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1384 11345.00000 112856.9300 9.9477
OCCT-97530-OT SESSION BY LICENSED OT 40 203.500000 13892.8600 68.2696
OCCT-97530HM-OT SESSION BY OT ASST 1 3.000000 171.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 77 438.250000 28725.9700 65.5470
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 215 1289.000000 87371.7200 67.7826
SPL-92508-GROUP SPL SESSION PER CHILD 6 23.000000 315.3600 13.7113
TRAV-TRAVS-Travel by mile 798 74744.00000 32119.2900 0.4297
Subtotal (Total Children Is Unduplicated) 1627 92007.25000 478048.7000 5.1958
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Total 101597.000000 829630.0500 8.1659
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Number of Children (Unduplicated) With at Least One Service 2733
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Center 01
Flag Claims Units Chgs Paid
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R 4 2.750000 177.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 7546 5116.000000 202441.9600 0.0000
P 19605 78712.750000 388468.0500 388468.0500
D 1179 5284.500000 39679.3500 0.0000
S 170 143.250000 7342.9300 0.0000
H 264 286.000000 19628.0600 0.0000
T 1221 7413.500000 19721.4800 19721.4800
6133 4361.250000 135233.0600 0.0000
Other 220 277.000000 16937.4100 0.0000
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Total 36342 101597.000000 829630.0500 408189.5300