CMS/EIP Fiscal Report Center: 05
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 386 165.000000 6105.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 428 409.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1152 2769.500000 102471.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1186 3344.000000 108576.5000 32.4690
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 50 57.250000 2862.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 1.000000 75.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 1.000000 75.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 13.500000 749.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 49 76.500000 5737.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 8.500000 637.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 92 132.500000 9937.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 69 93.500000 5189.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 29.000000 2175.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 4.000000 160.2600 40.0650
PSTH-97163-PT EVAL HIGH COMPLEXITY 8 9.000000 459.4500 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 3 3.000000 108.1500 36.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 16 16.000000 816.8000 51.0500
Subtotal (Total Children Is Unduplicated) 239 449.750000 29334.2100 65.2234
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 84 97.750000 4887.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 0.750000 18.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 116 81.500000 4075.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 3 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 42 28.250000 1412.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 29 18.500000 925.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 3 0.750000 18.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 64 36.250000 1812.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 4 1.250000 31.2500 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 22 92.000000 2300.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 223 1366.500000 68325.0000 50.0000
INTR-T1013-INTERPRETER 10 69.000000 3450.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 666 4648.000000 46155.1200 9.9301
OCCT-97530-OT SESSION BY LICENSED OT 31 105.500000 6741.2300 63.8979
PHY-97110-PT SESSION BY LICENSED PT 44 152.250000 9359.3700 61.4737
PHY-97110HM-PT SESSION BY PT ASST 2 6.500000 60.8700 9.3646
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 115 553.500000 36480.6200 65.9090
TRAV-TRAVS-Travel by mile 724 72847.00000 32268.6900 0.4430
Subtotal (Total Children Is Unduplicated) 771 80107.25000 218372.1500 2.7260
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Total 83901.000000 356282.8600 4.2465
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Number of Children (Unduplicated) With at Least One Service 1272
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Center 05
Flag Claims Units Chgs Paid
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R 15 11.250000 501.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2396 1571.250000 60631.0000 43378.9900
P 6344 74381.500000 226168.6200 226168.6200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3573 7937.000000 68982.2400 15628.2400
Other 0 0.000000 0.0000 0.0000
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Total 12328 83901.000000 356282.8600 285175.8500