CMS/EIP Fiscal Report Center: 09
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 1918 4421.000000 163530.7500 36.9895
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 983 864.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2194 7578.250000 280173.2500 36.9707
Subtotal (Total Children Is Unduplicated) 2369 12863.75000 443704.0000 34.4926
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 141 280.500000 14025.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 10.000000 640.1100 64.0110
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 7.500000 562.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 17.000000 1275.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 8.500000 471.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 361 580.500000 42509.2200 73.2286
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 158 256.500000 18680.4500 72.8283
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 200 341.500000 25356.0600 74.2491
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 442 753.000000 40983.1300 54.4265
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 215 331.000000 24131.9700 72.9063
NUTR-97802-NUTRITIONAL EVAL, INITIAL 2 19.000000 950.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 7 45.000000 2250.0000 50.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 12 12.000000 542.6000 45.2167
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 97.8800 48.9400
Subtotal (Total Children Is Unduplicated) 850 2676.500000 173293.4200 64.7463
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 165 262.250000 13112.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 48 49.000000 1225.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 20 28.500000 1425.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 24 26.000000 1300.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 3 3.000000 75.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 34 40.750000 2037.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 42 47.750000 2387.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 260 325.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1277 9033.000000 449020.5600 49.7089
INTR-T1013-INTERPRETER 90 246.250000 11550.5000 46.9056
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 117 796.000000 7960.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 139 1055.500000 73789.3500 69.9094
PHY-97110-PT SESSION BY LICENSED PT 209 1801.000000 126197.6600 70.0709
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 497 4232.500000 294434.0300 69.5650
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.000000 55.5200 13.8800
TRAV-TRAVS-Travel by mile 1653 162146.0000 71545.0200 0.4412
Subtotal (Total Children Is Unduplicated) 1850 180098.7500 1056165.1400 5.8644
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Total 195639.000000 1673162.5600 8.5523
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Number of Children (Unduplicated) With at Least One Service 2483
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Center 09
Flag Claims Units Chgs Paid
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R 202 241.250000 8926.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1777 1735.750000 68885.5000 124.5000
P 22460 170274.500000 1048572.5400 1048584.4900
D 11 11.000000 785.8400 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
3537 22956.500000 515154.4300 0.0000
Other 257 420.000000 30838.0000 0.0000
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Total 28244 195639.000000 1673162.5600 1048708.9900