CMS/EIP Fiscal Report Center: 52
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 436 229.750000 8500.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 317 214.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 884 2530.500000 93406.5000 36.9123
Subtotal (Total Children Is Unduplicated) 975 2975.000000 101907.2500 34.2545
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 13 13.000000 650.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 33.000000 2325.0000 70.4545
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 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 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 31.000000 1720.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 211 447.500000 31392.6300 70.1511
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 93 196.000000 14202.9700 72.4641
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 39 75.000000 5415.2900 72.2039
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 219 429.000000 23759.5000 55.3834
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 30.000000 2250.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 15 15.000000 765.7500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 7 7.000000 357.3500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
SCREEN-T1023-SCREENING 37 37.000000 1850.0000 50.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 26 26.000000 1326.2500 51.0096
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 334 1358.500000 87296.5400 64.2595
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 158 189.750000 9487.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 6 3.250000 81.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 130 189.500000 9475.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 8 5.750000 143.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 98 243.750000 12187.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 41 44.000000 2200.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 103 161.000000 8050.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 3 2.500000 62.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 99 143.500000 0.0000 0.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 5.000000 207.0000 41.4000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 368 2243.000000 111760.0000 49.8261
INTR-T1013-INTERPRETER 3 32.250000 1612.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 634 5330.000000 53300.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 116 550.250000 39024.1000 70.9207
OCCT-97530HM-OT SESSION BY OT ASST 34 143.500000 8208.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 67 377.750000 25364.6400 67.1466
PHY-97110HM-PT SESSION BY PT ASST 3 23.000000 1314.6800 57.1600
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 262 1498.250000 105010.3800 70.0887
TRAV-TRAVS-Travel by mile 593 52999.00000 23589.4600 0.4451
Subtotal (Total Children Is Unduplicated) 732 64186.00000 411096.4600 6.4048
-----------------------------------------------------------------------------------------------------------------------
Total 68519.500000 600300.2500 8.7610
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1033
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 80 92.250000 5023.7500 37.0000
P 3129 2932.250000 140535.1800 137513.9700
D 149 169.500000 9046.9600 0.0000
S 41 34.750000 1507.7500 0.0000
H 148 205.750000 13732.5900 0.0000
T 7164 61032.750000 257030.7800 245208.7700
4297 4052.250000 173423.2400 472.0600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15008 68519.500000 600300.2500 383231.8000