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
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 305 153.000000 5661.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 368 383.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 368 1037.750000 38378.2500 36.9822
Subtotal (Total Children Is Unduplicated) 667 1574.500000 44039.2500 27.9703
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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 5 8.000000 600.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 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 53 83.000000 6225.0000 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 39 55.000000 4125.0000 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 19 32.000000 2400.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH 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) 151 332.500000 21887.4500 65.8269
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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 197 970.250000 48512.5000 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 11 41.000000 2205.4800 53.7922
PHY-97110-PT SESSION BY LICENSED PT 18 53.250000 2875.2600 53.9955
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 37 153.000000 10351.2000 67.6549
TRAV-TRAVS-Travel by mile 658 61373.00000 27315.3300 0.4451
Subtotal (Total Children Is Unduplicated) 679 66474.00000 147827.2700 2.2238
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Total 68381.000000 213753.9700 3.1259
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Number of Children (Unduplicated) With at Least One Service 917
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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 0 0.000000 0.0000 0.0000
P 5479 66727.500000 169631.7800 169628.6640
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
2603 1653.500000 44122.1900 63.8000
Other 0 0.000000 0.0000 0.0000
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Total 8082 68381.000000 213753.9700 169692.4640