CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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 690 273.750000 10128.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 756 719.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2772 8204.000000 303344.5000 36.9752
Subtotal (Total Children Is Unduplicated) 2805 9197.000000 313473.2500 34.0843
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 10 10.000000 485.0000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 241 453.750000 22475.0000 49.5317
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 26.000000 1950.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 36 92.500000 6937.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 19 39.000000 2164.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 197 283.000000 20728.6200 73.2460
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 27.000000 2025.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 30 46.000000 3450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 444 700.500000 38850.0000 55.4604
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 347 619.500000 46250.6400 74.6580
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 80.6100 40.3050
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 48.9400 48.9400
Subtotal (Total Children Is Unduplicated) 868 2322.250000 146711.5600 63.1765
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 103.0600 103.0600
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 59.0000 59.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 229 322.750000 15712.5000 48.6832
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.750000 43.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 94 150.500000 7475.0000 49.6678
CONIP-CONIP-CONSULT, ITDS PHONE 7 6.500000 156.2500 24.0385
CONOF-CONOF-CONSULT, OT, FACE TO FACE 29 39.750000 1987.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 1.500000 37.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 40 47.500000 2375.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 4 3.000000 75.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 69 93.250000 4662.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 9 6.750000 168.7500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 594 3651.000000 182375.0000 49.9521
INTR-T1013-INTERPRETER 280 758.750000 37403.2500 49.2959
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1550 12108.00000 120773.5400 9.9747
OCCT-97530-OT SESSION BY LICENSED OT 64 423.000000 28987.0100 68.5272
OCCT-97530HM-OT SESSION BY OT ASST 2 9.750000 557.7000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 83 436.750000 29205.6100 66.8703
PHY-97110HM-PT SESSION BY PT ASST 6 22.000000 1257.5200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 158 784.750000 50724.3600 64.6376
SPL-92508-GROUP SPL SESSION PER CHILD 8 41.000000 569.0800 13.8800
TRAV-TRAVS-Travel by mile 958 78967.00000 33340.5300 0.4222
Subtotal (Total Children Is Unduplicated) 1922 97879.25000 518149.4100 5.2938
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Total 109398.500000 978334.2200 8.9428
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Number of Children (Unduplicated) With at Least One Service 2955
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Center 01
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 211 227.500000 13331.6000 0.0000
P 21809 91013.250000 393529.4300 393345.1100
D 448 1492.000000 11676.2100 0.0000
S 4489 4568.500000 159185.1500 0.0000
H 6418 4625.000000 199951.4000 173847.1300
T 904 2558.250000 18978.7100 18960.2100
6736 4474.000000 153225.2200 0.0000
Other 299 440.000000 28456.5000 0.0000
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Total 41314 109398.500000 978334.2200 586152.4500