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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 11.000000 825.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 11.500000 862.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 8.000000 416.2500 52.0313
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 52 83.500000 5939.2800 71.1291
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 26 39.500000 2857.0100 72.3294
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 56 98.500000 5355.7500 54.3731
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 44.500000 3262.5000 73.3146
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 127 307.000000 20207.4400 65.8223
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 4.000000 3348.1200 837.0300
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.000000 100.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 8 8.500000 425.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 250 1553.500000 77650.0000 49.9839
INTR-T1013-INTERPRETER 2 1.250000 62.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 25 105.500000 7151.4800 67.7865
PHY-97110-PT SESSION BY LICENSED PT 35 175.250000 10540.8600 60.1476
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 126 672.750000 45162.5600 67.1313
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.000000 23.8800 11.9400
Subtotal (Total Children Is Unduplicated) 369 2529.750000 144625.4000 57.1698
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Total 2836.750000 164832.8400 58.1062
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Number of Children (Unduplicated) With at Least One Service 440
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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 1998 2019.750000 112170.8600 112170.8600
D 249 249.250000 14750.7900 0.0000
S 0 0.000000 0.0000 0.0000
H 264 286.000000 19628.0600 0.0000
T 68 66.750000 3975.4400 3975.4400
149 185.000000 12217.2500 0.0000
Other 19 30.000000 2090.4400 0.0000
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Total 2747 2836.750000 164832.8400 116146.3000