CMS/EIP Fiscal Report Center: 55
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 1190 1416.250000 52401.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 364 306.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1311 4807.500000 177840.5000 36.9923
Subtotal (Total Children Is Unduplicated) 1390 6529.750000 230241.7500 35.2604
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
EVAL-96111-DEVELOPMENTAL EVALUATION 28 56.000000 2800.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 46 59.000000 2950.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 28.000000 2099.9999 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 20.000532 1500.0400 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 253 505.333204 37899.9901 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 177 353.000006 26475.0004 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 24.000000 1800.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 65 131.500000 7298.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 63 124.000134 9300.0100 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 22 22.000000 1123.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 14 14.000000 714.7000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 25 25.000000 1276.2500 51.0500
Subtotal (Total Children Is Unduplicated) 478 1385.833876 96582.4904 69.6927
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 6.000000 300.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 84 89.500000 4475.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 118 131.750000 3293.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 35 50.000000 2500.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 50 85.000000 2125.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 1.500000 75.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 77 83.000000 4150.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 100 94.000000 2350.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 12 38.750000 968.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 435 2631.820000 131591.0000 50.0000
INTR-T1013-INTERPRETER 1 5.000000 312.0000 62.4000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 784 6187.000000 61870.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 129 695.650057 49697.2400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 150 742.862586 42491.7400 57.2000
PHY-97110-PT SESSION BY LICENSED PT 77 427.510078 30541.3200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 54 278.244932 15904.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 254 1631.636757 116564.1300 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 2.000000 114.4000 57.2000
TRAV-TRAVS-Travel by mile 178 10526.00000 4682.9800 0.4449
Subtotal (Total Children Is Unduplicated) 852 23707.22441 474006.7900 19.9942
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Total 31622.808286 800831.0304 25.3245
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Number of Children (Unduplicated) With at Least One Service 1410
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Center 55
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 1752 1510.250000 63348.0000 96.2500
P 11152 18868.239438 285623.8101 294097.0400
D 0 0.000000 0.0000 0.0000
S 2 2.666666 200.0000 0.0000
H 9 18.500000 1292.5000 0.0000
T 1 0.750000 27.7500 27.7500
11798 11222.402182 450338.9703 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 24714 31622.808286 800831.0304 294221.0400