CMS/EIP Fiscal Report Center: 52
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 559 297.750000 10998.2500 36.9379
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 313 202.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 977 2882.250000 105616.5000 36.6438
Subtotal (Total Children Is Unduplicated) 1093 3382.500000 116614.7500 34.4759
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 7 7.000000 350.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 20 39.000000 2925.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 20.000000 1500.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 39.000000 2164.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 235 483.000000 34969.8600 72.4014
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 151 296.500000 22237.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 50 96.000000 6970.5800 72.6102
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 259 507.000000 28128.1500 55.4796
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 26.000000 1800.0000 69.2308
OCTH-97166-OT EVAL MODERATE COMPLEXITY 11 11.000000 561.5500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 38 38.000000 1900.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 17 17.000000 867.8500 51.0500
Subtotal (Total Children Is Unduplicated) 356 1593.500000 105233.3900 66.0392
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 155 178.000000 8900.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.500000 37.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 104 159.000000 7950.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 8 11.000000 275.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 88 141.000000 7050.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 30 34.250000 1712.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 5 3.000000 75.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 51 61.500000 3075.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 3 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 125 184.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 387 2132.250000 106199.5000 49.8063
INTR-T1013-INTERPRETER 2 13.000000 650.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 641 4976.000000 49740.0000 9.9960
OCCT-97530-OT SESSION BY LICENSED OT 127 534.000000 37280.9600 69.8145
OCCT-97530HM-OT SESSION BY OT ASST 45 298.000000 16816.8000 56.4322
PHY-97110-PT SESSION BY LICENSED PT 63 385.750000 26600.7000 68.9584
PHY-97110HM-PT SESSION BY PT ASST 4 16.750000 957.4300 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 243 1516.500000 103137.2200 68.0100
TRAV-TRAVS-Travel by mile 589 49220.00000 21907.2100 0.4451
Subtotal (Total Children Is Unduplicated) 792 59867.00000 392389.8200 6.5544
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Total 64843.000000 614237.9600 9.4727
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Number of Children (Unduplicated) With at Least One Service 1161
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Center 52
Flag Claims Units Chgs Paid
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R 7 3.500000 142.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1090 1102.500000 54661.5000 83.2500
P 2526 2442.750000 109837.6700 107098.7700
D 41 58.500000 3244.0900 150.0000
S 6 7.000000 259.0000 0.0000
H 184 277.000000 18634.1400 0.0000
T 6795 56806.000000 238135.9400 227696.1300
4425 4145.750000 189323.1200 268.7300
Other 0 0.000000 0.0000 0.0000
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Total 15074 64843.000000 614237.9600 335296.8800