CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
Payclass Filters:TPIN
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 4 2.500000 92.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7 8.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 33 86.750000 3209.7500 37.0000
Subtotal (Total Children Is Unduplicated) 37 97.750000 3302.2500 33.7826
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 2.000000 97.0000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.500000 360.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 31 50.500000 3787.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 10.000000 750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 13.500000 1012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 30.000000 1665.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 22.500000 1650.0000 73.3333
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 63 149.500000 10337.3500 69.1462
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EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 10 6.500000 325.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 11 17.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 102 547.820000 27391.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 10 25.000000 250.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 57.240000 4089.3700 71.4425
PHY-97110-PT SESSION BY LICENSED PT 13 42.800000 3060.0200 71.4958
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 13 96.000000 6858.2400 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 146 793.360000 41987.5100 52.9237
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Total 1040.610000 55627.1100 53.4563
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Number of Children (Unduplicated) With at Least One Service 192
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Center 54
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 93 93.250000 5010.2700 5010.2700
T 22 23.000000 1279.2000 1279.2000
904 924.360000 49337.6400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1019 1040.610000 55627.1100 6289.4700