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:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 132 94.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 145 236.750000 8759.7500 37.0000
Subtotal (Total Children Is Unduplicated) 145 331.250000 8759.7500 26.4445
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 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 77 126.000000 9450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 65 108.000000 8100.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 22.500000 1687.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 143 235.500000 13070.2500 55.5000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 4.000000 200.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 4 15.000000 750.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 165 519.500000 33768.1000 65.0012
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 31 43.750000 2187.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 13 12.500000 312.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 5 8.000000 400.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 8 8.000000 400.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 8.000000 400.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 8 9.000000 450.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 236 1098.000000 52570.5600 47.8785
OCCT-97530-OT SESSION BY LICENSED OT 35 140.000000 10001.6000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 57 251.000000 17931.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 186 1212.000000 85982.1000 70.9423
TRAV-TRAVS-Travel by mile 775 44263.00000 19491.8800 0.4404
Subtotal (Total Children Is Unduplicated) 830 47053.25000 190127.5800 4.0407
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Total 47904.000000 232655.4300 4.8567
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Number of Children (Unduplicated) With at Least One Service 971
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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 2797 47866.750000 230466.1400 230466.1400
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
16 37.250000 2189.2900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2813 47904.000000 232655.4300 230466.1400