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
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 386 165.000000 6105.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 428 409.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 489 1268.250000 46925.2500 37.0000
Subtotal (Total Children Is Unduplicated) 819 1842.750000 53030.2500 28.7778
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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 1 0.500000 37.5000 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 52 74.500000 5587.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 66 89.500000 4967.2500 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 5 6.000000 306.3000 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 15 15.000000 765.7500 51.0500
Subtotal (Total Children Is Unduplicated) 195 379.250000 24244.4600 63.9274
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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 20 86.000000 2150.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 215 1335.000000 66750.0000 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 20 75.500000 4614.8200 61.1234
PHY-97110-PT SESSION BY LICENSED PT 28 87.250000 4772.5500 54.6997
PHY-97110HM-PT SESSION BY PT ASST 2 6.500000 60.8700 9.3646
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 98 409.000000 26208.3400 64.0791
TRAV-TRAVS-Travel by mile 724 72847.00000 32268.6900 0.4430
Subtotal (Total Children Is Unduplicated) 767 79830.25000 199661.6400 2.5011
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Total 82052.250000 276936.3500 3.3751
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Number of Children (Unduplicated) With at Least One Service 1080
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Center 05
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 1 0.250000 9.2500 0.0000
P 6225 74130.500000 208635.0200 208635.0200
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
3557 7921.500000 68292.0800 15271.0800
Other 0 0.000000 0.0000 0.0000
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Total 9783 82052.250000 276936.3500 223906.1000