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
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 690 273.750000 10128.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 756 719.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 936 2694.500000 99622.5000 36.9725
Subtotal (Total Children Is Unduplicated) 1773 3687.500000 109751.2500 29.7631
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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 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 7.000000 525.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 29 47.000000 3362.2600 71.5374
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 66 109.000000 6021.7500 55.2454
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 42 75.000000 5484.0700 73.1209
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 340 726.750000 39984.9800 55.0189
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EI Services,Class #03
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-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 122 644.500000 32200.0000 49.9612
INTR-T1013-INTERPRETER 280 755.750000 37253.2500 49.2931
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1550 12108.00000 120773.5400 9.9747
OCCT-97530-OT SESSION BY LICENSED OT 9 42.000000 2677.3700 63.7469
PHY-97110-PT SESSION BY LICENSED PT 14 69.500000 4511.1000 64.9079
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 127.500000 8204.1300 64.3461
SPL-92508-GROUP SPL SESSION PER CHILD 2 11.000000 152.6800 13.8800
TRAV-TRAVS-Travel by mile 958 78967.00000 33340.5300 0.4222
Subtotal (Total Children Is Unduplicated) 1775 93398.50000 271806.3500 2.9102
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Total 97812.750000 421542.5800 4.3097
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Number of Children (Unduplicated) With at Least One Service 2510
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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 0 0.000000 0.0000 0.0000
P 19066 88238.500000 247410.0900 247225.7700
D 287 1328.500000 3514.7100 0.0000
S 548 1471.000000 13068.7800 0.0000
H 2 3.000000 171.4400 0.0000
T 780 2440.750000 12211.5100 12211.5100
6583 4331.000000 145166.0500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 27266 97812.750000 421542.5800 259437.2800