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: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 247 102.750000 3801.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 37 27.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 610 1850.500000 68468.5000 37.0000
Subtotal (Total Children Is Unduplicated) 778 1981.000000 72270.2500 36.4817
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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 102 87.000000 6525.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 11.500000 862.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 148 144.500000 8019.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 54 57.000000 4275.0000 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) 327 563.000000 33034.3000 58.6755
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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 1002 8160.000000 81600.0000 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 32 9742.000000 4335.3000 0.4450
Subtotal (Total Children Is Unduplicated) 1054 19925.00000 200988.5600 10.0873
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Total 22469.000000 306293.1100 13.6318
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Number of Children (Unduplicated) With at Least One Service 1446
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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 3431 19923.750000 202091.4900 202089.6600
2570 2453.750000 100868.5000 255.2500
Other 2 5.000000 50.0000 50.0000
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Total 6090 22469.000000 306293.1100 204873.3300