CMS/EIP Fiscal Report Center: 06
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 1438 1073.500000 39719.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 939 825.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 757 2300.250000 85109.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1737 4198.750000 124828.7500 29.7300
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 17 28.250000 1412.5000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 24.500000 1837.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 12.000000 900.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 18.500000 1387.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 24 37.000000 2053.5000 55.5000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 151.4400 75.7200
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 49 123.250000 7793.4900 63.2332
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 112 106.500000 5285.0000 49.6244
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 8 4.500000 112.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 21 23.500000 1175.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 13 10.000000 250.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 5 4.500000 225.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 5 5.000000 125.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 4.500000 225.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.250000 6.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 19 20.000000 1000.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 12 9.750000 243.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 81 422.000000 20800.0000 49.2891
INTR-T1013-INTERPRETER 12 73.000000 4628.0000 63.3973
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1201 9986.000000 99640.0000 9.9780
OCCT-97530-OT SESSION BY LICENSED OT 20 65.000000 4500.7200 69.2418
OCCT-97530HM-OT SESSION BY OT ASST 3 9.750000 557.5000 57.1795
PHY-97110-PT SESSION BY LICENSED PT 34 117.500000 7858.4000 66.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 250.750000 17843.5800 71.1608
SPL-92508-GROUP SPL SESSION PER CHILD 9 171.500000 2255.9200 13.1541
Subtotal (Total Children Is Unduplicated) 1215 11285.00000 166781.6200 14.7791
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Total 15607.000000 299403.8600 19.1839
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Number of Children (Unduplicated) With at Least One Service 1982
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Center 06
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 6743 6606.750000 99238.9600 99238.9600
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
12206 9000.250000 200164.9000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 18949 15607.000000 299403.8600 99238.9600