CMS/EIP Fiscal Report Center: 05
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 305 153.000000 5661.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 368 383.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 974 2639.750000 97596.7500 36.9720
Subtotal (Total Children Is Unduplicated) 984 3176.500000 103257.7500 32.5068
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 44 59.000000 2950.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 9.500000 712.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 7.500000 562.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 93 146.000000 10950.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.500000 562.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 75 95.500000 7162.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 53 73.000000 4051.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 49 76.500000 5737.5000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 357.3500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 234 496.000000 33934.4000 68.4161
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 88 81.750000 4087.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 0.250000 6.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 144 130.750000 6537.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 6 2.500000 62.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 23 19.750000 987.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 37 24.500000 1225.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 3 1.500000 37.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 87 62.000000 3100.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 0.500000 12.5000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 39 160.750000 4018.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 205 1011.000000 50550.0000 50.0000
INTR-T1013-INTERPRETER 17 64.250000 3142.5000 48.9105
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 600 3335.000000 33350.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 72.500000 4455.8400 61.4599
PHY-97110-PT SESSION BY LICENSED PT 29 84.000000 5072.0400 60.3814
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 63 296.750000 20620.7000 69.4885
TRAV-TRAVS-Travel by mile 658 61373.00000 27315.3300 0.4451
Subtotal (Total Children Is Unduplicated) 687 66720.75000 164581.4100 2.4667
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Total 70393.250000 301773.5600 4.2870
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Number of Children (Unduplicated) With at Least One Service 1061
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Center 05
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 2792 1787.750000 72294.0000 0.0000
P 5620 66951.000000 185320.3700 185317.2540
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 0 0.000000 0.0000 0.0000
2606 1654.500000 44159.1900 63.8000
Other 0 0.000000 0.0000 0.0000
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Total 11018 70393.250000 301773.5600 185381.0540