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
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 1638 1030.000000 38110.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 895 701.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 890 2246.750000 83108.0000 36.9903
Subtotal (Total Children Is Unduplicated) 2064 3978.500000 121218.0000 30.4683
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 25 46.500000 2285.0000 49.1398
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 31.500000 2005.8000 63.6762
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 13.000000 975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 24 38.000000 2109.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 7.500000 562.5000 75.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 83.2900 83.2900
Subtotal (Total Children Is Unduplicated) 54 137.500000 8020.5900 58.3316
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EI Services,Class #03
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 86 645.500000 31075.0000 48.1410
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 11 52.000000 3714.8800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 10 68.500000 4893.6400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 42 168.250000 11519.7000 68.4678
Subtotal (Total Children Is Unduplicated) 1425 13327.50000 184070.7200 13.8113
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Total 17443.500000 313309.3100 17.9614
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Number of Children (Unduplicated) With at Least One Service 2413
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Center 06
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 8432 8287.500000 115196.2300 115196.2300
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
12714 9156.000000 198113.0800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 21146 17443.500000 313309.3100 115196.2300