CMS/EIP Fiscal Report Center: 03
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 851 548.000000 20276.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 460 497.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1358 3342.250000 123654.0000 36.9972
Subtotal (Total Children Is Unduplicated) 1443 4387.250000 143930.0000 32.8064
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.000000 97.0000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 75 94.750000 4737.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 21 40.500000 3037.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 10.500000 787.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 11.000000 825.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 19 29.500000 1637.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 153 280.500000 21037.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 25 43.500000 3262.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 44 74.500000 5587.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 112 206.500000 11460.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 64.000000 4800.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 4 4.000000 165.8600 41.4650
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 10.2100 10.2100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 5 5.000000 178.0700 35.6140
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 7 7.000000 316.5200 45.2171
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 113 127.000000 6350.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 459.4500 51.0500
Subtotal (Total Children Is Unduplicated) 414 1023.250000 65557.4600 64.0679
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 227.2000 227.2000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 206 278.500000 13925.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 7 4.000000 100.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 334 572.750000 28637.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.500000 12.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 144 235.750000 11787.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 116 197.750000 9887.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 318 470.000000 23500.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 245 272.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 236 1093.750000 54687.5000 50.0000
INTR-T1013-INTERPRETER 4 22.250000 1057.7500 47.5393
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 165 825.000000 8250.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 29 151.250000 9087.5000 60.0826
OCCT-97530HM-OT SESSION BY OT ASST 3 4.000000 228.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 40 180.000000 12350.1100 68.6117
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 45 203.250000 13282.0700 65.3484
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
TRAV-TRAVS-Travel by mile 669 69167.00000 30769.9600 0.4449
Subtotal (Total Children Is Unduplicated) 774 73680.00000 217804.7700 2.9561
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Total 79090.500000 427292.2300 5.4026
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Number of Children (Unduplicated) With at Least One Service 1623
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Center 03
Flag Claims Units Chgs Paid
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R 83 57.000000 2109.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3491 2450.000000 104438.7500 0.0000
P 2781 27083.750000 68900.9800 68900.9800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 329 2999.750000 7473.5200 7473.5200
T 835 7246.500000 18192.7500 18192.7500
9550 39253.500000 226177.2300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 17069 79090.500000 427292.2300 94567.2500