CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2018 ending 03/31/2018 Date of Report:05/05/2018 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 141 481.250000 17806.2500 37.0000
Subtotal (Total Children Is Unduplicated) 141 481.250000 17806.2500 37.0000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 11 22.000000 1100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 48.000000 3542.8800 73.8100
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 26 45.000000 3375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 9.500000 712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 42.500000 2350.5000 55.3059
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
Subtotal (Total Children Is Unduplicated) 54 179.500000 11979.3800 66.7375
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 15 23.000000 1150.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 3 3.000000 150.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 3.000000 150.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 53 47.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 108 427.000000 21350.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 14 54.000000 3807.7600 70.5141
PHY-97110-PT SESSION BY LICENSED PT 14 35.000000 2500.4000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 45 219.000000 15573.1600 71.1103
TRAV-TRAVS-Travel by mile 322 15425.00000 6832.3500 0.4429
Subtotal (Total Children Is Unduplicated) 394 16239.50000 51638.6700 3.1798
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Total 16900.250000 81424.3000 4.8179
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Number of Children (Unduplicated) With at Least One Service 558
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Center 09
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 922 16019.500000 55247.9600 55247.9600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 61 111.500000 7603.3800 0.0000
T 0 0.000000 0.0000 0.0000
494 769.250000 18572.9600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1477 16900.250000 81424.3000 55247.9600