CMS/EIP Fiscal Report Center: 09
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 75 50.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 86 147.500000 5457.5000 37.0000
Subtotal (Total Children Is Unduplicated) 86 198.250000 5457.5000 27.5284
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 32 51.000000 3825.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 45 83.000000 6225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 78 135.500000 7520.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 9.000000 450.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 5 49.000000 2450.0000 50.0000
Subtotal (Total Children Is Unduplicated) 93 354.000000 22321.2500 63.0544
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 9 12.500000 625.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 4.000000 100.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 3 3.000000 150.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 3 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 245 1232.000000 61600.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 34 200.000000 14288.0000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 45 233.000000 16645.5200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 163 902.750000 64492.4600 71.4400
TRAV-TRAVS-Travel by mile 826 51573.00000 22584.5500 0.4379
Subtotal (Total Children Is Unduplicated) 870 54165.25000 180735.5300 3.3367
-----------------------------------------------------------------------------------------------------------------------
Total 54717.500000 208514.2800 3.8107
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 947
-----------------------------------------------------------------------------------------------------------------------
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 2423 54392.250000 192339.1500 192339.1500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 216 319.250000 15884.2500 0.0000
T 0 0.000000 0.0000 0.0000
5 6.000000 290.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2644 54717.500000 208514.2800 192339.1500