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
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 559 197.000000 7289.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1023 997.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 897 2283.250000 84406.2500 36.9676
Subtotal (Total Children Is Unduplicated) 1785 3477.250000 91695.2500 26.3700
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 16 16.000000 761.1300 47.5706
EXIT-EXIT-EXIT ASSESSMENT 177 352.750000 17575.0000 49.8228
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.500000 477.5000 73.4615
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 45.500000 2956.7100 64.9826
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.000000 450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 55 91.000000 4786.9900 52.6043
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 30.500000 1837.7400 60.2538
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 48.5000 48.5000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 270 560.750000 29669.1700 52.9098
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 1991.6900 995.8450
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 185 251.500000 12250.0000 48.7078
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 87 209.000000 10450.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 15 19.500000 975.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 33 53.000000 2650.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 76 145.500000 7275.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 157 729.250000 36379.5000 49.8862
INTR-T1013-INTERPRETER 220 644.000000 32195.0000 49.9922
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1384 11345.00000 112856.9300 9.9477
OCCT-97530-OT SESSION BY LICENSED OT 14 63.000000 4294.5600 68.1676
PHY-97110-PT SESSION BY LICENSED PT 31 169.000000 11469.7500 67.8683
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 85 426.500000 28653.4200 67.1827
SPL-92508-GROUP SPL SESSION PER CHILD 1 9.000000 124.9200 13.8800
TRAV-TRAVS-Travel by mile 798 74744.00000 32119.2900 0.4297
Subtotal (Total Children Is Unduplicated) 1550 88811.25000 293742.2200 3.3075
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Total 92849.250000 415106.6400 4.4708
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Number of Children (Unduplicated) With at Least One Service 2314
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Center 01
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 17503 76586.000000 270781.1400 270781.1400
D 751 4853.500000 13031.0100 0.0000
S 2 0.500000 18.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 1153 7346.750000 15746.0400 15746.0400
5890 4062.500000 115529.9500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 25299 92849.250000 415106.6400 286527.1800