CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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 1638 1030.000000 38110.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 895 701.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2208 5561.750000 205763.0000 36.9961
Subtotal (Total Children Is Unduplicated) 2373 7293.500000 243873.0000 33.4370
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 36 66.500000 3285.0000 49.3985
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 7.500000 562.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 265 425.000000 30918.3000 72.7489
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 135 225.000000 16875.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 374 608.500000 33327.7500 54.7703
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 120 180.500000 13537.5000 75.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 83.2900 83.2900
Subtotal (Total Children Is Unduplicated) 492 1529.500000 99664.0900 65.1612
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 117 113.250000 5637.5000 49.7792
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 11 9.000000 225.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 20 18.500000 912.5000 49.3243
CONIP-CONIP-CONSULT, ITDS PHONE 20 20.250000 506.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 3 3.500000 87.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 3.000000 150.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 5 4.500000 112.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 19 16.500000 812.5000 49.2424
CONSP-CONSP-CONSULT, SLP, PHONE 15 15.750000 393.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1107 8640.250000 430812.5000 49.8611
INTR-T1013-INTERPRETER 16 50.000000 2860.0000 57.2000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1410 12138.00000 121120.0000 9.9786
OCCT-97530-OT SESSION BY LICENSED OT 116 446.250000 31339.0100 70.2275
OCCT-97530HM-OT SESSION BY OT ASST 39 164.750000 9371.7400 56.8846
PHY-97110-PT SESSION BY LICENSED PT 72 395.500000 26223.6300 66.3050
PHY-97110HM-PT SESSION BY PT ASST 1 0.500000 3.5800 7.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 269 1353.000000 90755.5700 67.0773
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.000000 27.7600 13.8800
Subtotal (Total Children Is Unduplicated) 1450 23396.50000 721451.2900 30.8359
-----------------------------------------------------------------------------------------------------------------------
Total 32219.500000 1064988.3800 33.0542
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2515
-----------------------------------------------------------------------------------------------------------------------
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 11022 10464.250000 235053.7600 235053.7600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
27322 21755.250000 829934.6200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 38344 32219.500000 1064988.3800 235053.7600