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
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 436 229.750000 8500.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 317 214.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 312 945.250000 34928.0000 36.9511
Subtotal (Total Children Is Unduplicated) 742 1389.750000 43428.7500 31.2493
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 12 12.000000 600.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 11.500000 731.4200 63.6017
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.500000 400.5800 61.6277
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 287.5000 63.8889
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 12.500000 693.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 10 10.000000 510.5000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
SCREEN-T1023-SCREENING 4 4.000000 200.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 47 73.000000 4084.2500 55.9486
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 157 188.750000 9437.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 6 3.250000 81.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 129 187.500000 9375.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 8 5.250000 131.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 97 239.750000 11987.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 39 42.250000 2112.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 103 161.000000 8050.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 3 2.000000 50.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 99 142.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 33 103.750000 5187.5000 50.0000
INTR-T1013-INTERPRETER 3 32.250000 1612.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 634 5326.000000 53260.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 45 173.500000 12394.8400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 26 111.000000 6349.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 20 96.250000 6790.3800 70.5494
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 59 314.750000 22357.9000 71.0338
TRAV-TRAVS-Travel by mile 593 52958.00000 23571.2100 0.4451
Subtotal (Total Children Is Unduplicated) 724 60088.75000 172766.5300 2.8752
-----------------------------------------------------------------------------------------------------------------------
Total 61551.500000 220279.5300 3.5788
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 964
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 3 3.000000 110.0000 110.0000
D 11 10.250000 530.3500 0.0000
S 3 1.500000 55.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 6337 59571.750000 169591.9200 166632.3800
3177 1965.000000 49991.7600 174.0100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9531 61551.500000 220279.5300 166916.3900