CMS/EIP Fiscal Report Center: 03
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 786 514.750000 19045.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 460 415.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1231 3099.250000 114672.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1287 4029.750000 133718.0000 33.1827
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 3 3.000000 145.5000 48.5000
EVAL-96111-DEVELOPMENTAL EVALUATION 2 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 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 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 99.000000 7425.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 22 36.000000 2700.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 37.000000 2775.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 28.500000 1581.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 10.000000 750.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 3 5.000000 255.2500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 4.000000 130.1700 32.5425
SCREEN-T1023-SCREENING 3 5.000000 250.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 93 244.500000 17035.4700 69.6747
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 209 246.500000 12325.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 1.750000 43.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 243 470.250000 23512.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 3 2.250000 56.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 129 294.250000 14712.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 78 130.000000 6500.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 198 304.750000 15237.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 0.750000 18.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 165 738.000000 36900.0000 50.0000
INTR-T1013-INTERPRETER 44 704.500000 25231.2500 35.8144
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 658 4847.000000 48470.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 41 192.500000 13006.5300 67.5664
OCCT-97530HM-OT SESSION BY OT ASST 1 5.000000 286.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 40 172.250000 10013.1200 58.1313
PHY-97110HM-PT SESSION BY PT ASST 1 2.000000 114.3200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 56 301.000000 20563.2800 68.3165
TRAV-TRAVS-Travel by mile 581 74917.00000 33346.3700 0.4451
Subtotal (Total Children Is Unduplicated) 709 83329.75000 260337.1200 3.1242
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Total 87604.000000 411090.5900 4.6926
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Number of Children (Unduplicated) With at Least One Service 1413
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Center 03
Flag Claims Units Chgs Paid
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R 26 30.750000 1488.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 3053 2000.250000 81356.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 1 1.750000 64.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
16262 85571.250000 328181.0900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 19342 87604.000000 411090.5900 0.0000