CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2018 ending 06/30/2018 Date of Report:08/10/2018 Page: 1
List order: No List
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 864 1192.500000 44086.5000 36.9698
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 702 903.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1094 3055.000000 112988.7500 36.9849
Subtotal (Total Children Is Unduplicated) 1198 5150.500000 157075.2500 30.4971
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 5 4.250000 212.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 19.500000 1462.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 19 44.000000 3300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 13 23.500000 1762.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 32 67.500000 3746.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 55 87.000000 6525.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 40 62.000000 4650.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 21.500000 1612.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 213 359.000000 19924.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 182 328.000000 24600.0000 75.0000
NURS-T1001-NURSING ASSESSMENT 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 313 1019.750000 68006.7500 66.6896
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 4.000000 872.9400 218.2350
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 53 38.250000 1912.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.250000 31.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 324 889.000000 44450.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 29 15.500000 387.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 5 3.250000 162.5000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 10 20.000000 1466.4000 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 624 1986.750000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 24 41.750000 1043.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 714 4239.500000 211962.0000 49.9969
INTR-T1013-INTERPRETER 3 10.000000 620.0000 62.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 886 7218.000000 72161.0000 9.9974
OCCT-97530-OT SESSION BY LICENSED OT 15 108.459991 7748.3814 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 4 12.000000 686.4000 57.2000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 31.000000 2214.6400 71.4400
TRAV-TRAVS-Travel by mile 535 54305.00000 24171.8500 0.4451
Subtotal (Total Children Is Unduplicated) 889 68923.70999 369891.1114 5.3667
-----------------------------------------------------------------------------------------------------------------------
Total 75093.959991 594973.1114 7.9230
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1278
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.500000 68.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 17 13.750000 656.7500 9.2500
P 4198 3881.056600 175761.3300 175175.6600
D 0 0.000000 0.0000 0.0000
S 29 25.750000 1055.7500 0.0000
H 2661 20421.851483 36536.7500 36536.7500
T 2119 13640.500000 27283.3500 27283.3500
17762 36952.551908 344583.1814 0.0000
Other 129 157.000000 9027.5000 0.0000
---------------------------------------------------------
Total 26917 75093.959991 594973.1114 239005.0100