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
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 851 548.000000 20276.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 460 497.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 544 1305.250000 48294.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1211 2350.250000 68570.2500 29.1757
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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 10 16.000000 1200.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 7.000000 525.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 17.000000 943.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 71 137.500000 10312.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 28.500000 2137.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 30.000000 2250.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 57 109.000000 6049.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 29.500000 2212.5000 75.0000
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 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 92 104.000000 5200.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 277 599.250000 37009.9500 61.7605
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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 215 1015.750000 50787.5000 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 20 75.500000 5379.4800 71.2514
OCCT-97530HM-OT SESSION BY OT ASST 3 4.000000 228.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 28 122.500000 8751.4000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 32 143.000000 10215.9200 71.4400
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) 769 73408.50000 203531.8900 2.7726
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Total 76358.000000 309112.0900 4.0482
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Number of Children (Unduplicated) With at Least One Service 1490
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Center 03
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 2702 27006.750000 64911.5800 64911.5800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 327 2997.750000 7358.7000 7358.7000
T 818 7229.500000 17240.1600 17240.1600
9406 39124.000000 219601.6500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 13253 76358.000000 309112.0900 89510.4400