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
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 576 294.500000 10896.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 737 716.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 909 2679.250000 99132.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1696 3690.500000 110028.7500 29.8141
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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 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 14.000000 1050.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 52 81.000000 6075.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 111 175.500000 9691.6900 55.2233
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 77 136.500000 10237.5000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 342 792.750000 46371.9900 58.4951
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 793.6800 396.8400
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 124 645.750000 32275.0000 49.9806
INTR-T1013-INTERPRETER 348 689.750000 33926.2500 49.1863
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1583 11421.00000 114057.0800 9.9866
OCCT-97530-OT SESSION BY LICENSED OT 5 14.000000 1000.1600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 18 82.500000 5491.5600 66.5644
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 29 100.500000 6546.8000 65.1423
SPL-92508-GROUP SPL SESSION PER CHILD 2 9.000000 124.9200 13.8800
TRAV-TRAVS-Travel by mile 1005 78887.00000 33457.3800 0.4241
Subtotal (Total Children Is Unduplicated) 1850 92614.75000 262654.0800 2.8360
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Total 97098.000000 419054.8200 4.3158
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Number of Children (Unduplicated) With at Least One Service 2468
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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 0 0.000000 0.0000 0.0000
P 18784 88861.750000 239432.0900 239432.0900
D 138 729.500000 1879.6500 0.0000
S 271 1695.250000 5230.1300 0.0000
H 0 0.000000 0.0000 0.0000
T 361 1104.750000 6309.6400 6309.6400
6884 4706.750000 166203.3100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 26438 97098.000000 419054.8200 245741.7300