CMS/EIP Fiscal Report Center: 57
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 244 100.750000 3727.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 37 27.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 586 1770.500000 65508.5000 37.0000
Subtotal (Total Children Is Unduplicated) 754 1899.000000 69236.2500 36.4593
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 102 183.000000 9150.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 5.000000 277.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 93 78.500000 5887.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 9.500000 712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 132 130.500000 7242.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 48 51.500000 3862.5000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 4 4.000000 204.2000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 12 12.000000 612.6000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 7 7.000000 357.3500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 12 12.000000 612.6000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 32 32.000000 1633.6000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 310 533.000000 31057.3000 58.2689
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EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 2.000000 100.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 47 47.000000 2350.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 5.000000 250.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 146 145.000000 7250.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 153 1070.000000 53500.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 997 8150.000000 81500.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 34 185.500000 13252.1200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 4.000000 228.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 27 117.500000 8394.2000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 13 136.500000 7802.3400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 54 292.500000 20896.2000 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 18.000000 1029.6000 57.2000
TRAV-TRAVS-Travel by mile 31 9597.000000 4270.7700 0.4450
Subtotal (Total Children Is Unduplicated) 1049 19770.00000 200824.0300 10.1580
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Total 22202.000000 301117.5800 13.5626
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Number of Children (Unduplicated) With at Least One Service 1417
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Center 57
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 15 20.250000 805.7500 0.0000
S 72 66.250000 2477.3700 2478.4200
H 0 0.000000 0.0000 0.0000
T 3420 19768.750000 201926.9600 201925.1300
2472 2341.750000 95857.5000 255.2500
Other 2 5.000000 50.0000 50.0000
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Total 5981 22202.000000 301117.5800 204708.8000