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
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 1918 4421.000000 163530.7500 36.9895
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 852 770.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 873 2995.500000 110787.2500 36.9846
Subtotal (Total Children Is Unduplicated) 2117 8186.500000 274318.0000 33.5086
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 140 278.500000 13925.0000 50.0000
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 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 49 80.500000 6037.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 19.500000 1462.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 44 78.000000 5850.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 37 64.000000 3552.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 56 87.000000 6525.0000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 2 15.000000 750.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 7 30.000000 1500.0000 50.0000
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 289 658.000000 39937.3500 60.6951
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 138 218.500000 10925.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 35 36.500000 912.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 18 20.500000 1025.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 16 18.000000 900.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 3 3.000000 75.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 31 32.750000 1637.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 34 38.750000 1937.5000 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 406 2133.000000 106650.0000 50.0000
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 65 350.000000 25004.0000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 101 613.000000 43623.3400 71.1637
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 268 1518.000000 105343.3200 69.3961
TRAV-TRAVS-Travel by mile 1529 117883.0000 52053.1400 0.4416
Subtotal (Total Children Is Unduplicated) 1723 124234.5000 369646.8000 2.9754
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Total 133079.000000 683902.1500 5.1391
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Number of Children (Unduplicated) With at Least One Service 2325
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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 16242 118542.250000 646458.9200 646458.9200
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
647 14533.750000 37276.7300 0.0000
Other 2 3.000000 166.5000 0.0000
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Total 16891 133079.000000 683902.1500 646458.9200