CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 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 576 294.500000 10896.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 737 716.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2627 8117.500000 300347.5000 37.0000
Subtotal (Total Children Is Unduplicated) 2649 9128.750000 311244.0000 34.0949
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 9 9.000000 436.5000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 182 357.250000 17562.5000 49.1603
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 24.000000 1800.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 34 82.500000 6187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 17.000000 943.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 216 332.000000 24419.9300 73.5540
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 21 28.500000 2137.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 31 45.000000 3375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 472 744.500000 41191.1900 55.3273
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 345 591.500000 44362.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 6 6.000000 306.3000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.1000 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 10.5500 10.5500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 810 2253.750000 143560.1700 63.6984
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 5.000000 2503.8400 500.7680
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 230 314.500000 15537.5000 49.4038
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 7 7.500000 168.7500 22.5000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 89 153.000000 7550.0000 49.3464
CONIP-CONIP-CONSULT, ITDS PHONE 19 26.000000 637.5000 24.5192
CONOF-CONOF-CONSULT, OT, FACE TO FACE 39 54.250000 2712.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 3 3.500000 68.7500 19.6429
CONPF-CONPF-CONSULT, PT, FACE TO FACE 46 90.750000 3037.5000 33.4711
CONPP-CONPP-CONSULT, PT, PHONE 3 2.750000 68.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 63 97.000000 4850.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 13 14.000000 350.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 585 3360.500000 167946.4400 49.9766
INTR-T1013-INTERPRETER 349 694.250000 34151.2500 49.1916
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1583 11421.00000 114057.0800 9.9866
OCCT-97530-OT SESSION BY LICENSED OT 55 345.750000 24230.3300 70.0805
OCCT-97530HM-OT SESSION BY OT ASST 2 4.000000 228.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 87 494.750000 33961.4400 68.6436
PHY-97110HM-PT SESSION BY PT ASST 6 16.000000 914.5600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 143 753.500000 49312.7800 65.4450
SPL-92508-GROUP SPL SESSION PER CHILD 7 29.000000 402.5200 13.8800
TRAV-TRAVS-Travel by mile 1005 78887.00000 33457.3800 0.4241
Subtotal (Total Children Is Unduplicated) 1980 96774.00000 496147.6700 5.1269
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Total 108156.500000 950951.8400 8.7924
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Number of Children (Unduplicated) With at Least One Service 2815
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Center 01
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 202 201.250000 14319.3000 0.0000
P 21333 91426.250000 376272.1100 376272.1100
D 255 848.000000 8021.0000 0.0000
S 2829 3652.250000 91478.2300 0.0000
H 7132 5314.500000 232411.4800 208392.6000
T 465 1207.250000 12379.0100 12379.0100
7128 4951.000000 180464.4600 0.0000
Other 348 556.000000 35606.2500 0.0000
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Total 39692 108156.500000 950951.8400 597043.7200