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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 144 86.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 161 260.000000 9573.7500 36.8221
Subtotal (Total Children Is Unduplicated) 161 346.500000 9573.7500 27.6299
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.500000 487.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 10.500000 582.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 80 120.000000 9000.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 69 122.000000 9150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 10.500000 787.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 150 243.500000 13514.2500 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) 169 580.000000 37097.0000 63.9603
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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
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Total 55091.750000 227406.2800 4.1278
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Number of Children (Unduplicated) With at Least One Service 1024
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Center 09
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 2519 54515.750000 198696.4000 198696.4000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 413 569.750000 28409.7500 0.0000
T 0 0.000000 0.0000 0.0000
6 6.250000 300.1300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2938 55091.750000 227406.2800 198696.4000