CMS/EIP Fiscal Report Center: 03
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 726 448.250000 16585.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 411 385.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1278 3397.250000 125633.5000 36.9809
Subtotal (Total Children Is Unduplicated) 1319 4231.250000 142218.7500 33.6115
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.000000 97.0000 48.5000
EVAL-96111-DEVELOPMENTAL EVALUATION 1 1.000000 50.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 65 90.000000 4500.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 23 39.500000 2962.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 13.500000 1012.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 28.000000 1554.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 189 335.000000 25125.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 79 134.000000 10050.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 27 48.000000 3600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 138 232.500000 12903.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 75.500000 5662.5000 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
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
SCREEN-T1023-SCREENING 79 96.000000 4800.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 411 1123.500000 74047.6000 65.9080
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 203 252.750000 12637.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 15 10.250000 256.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 322 636.250000 31743.7500 49.8919
CONIP-CONIP-CONSULT, ITDS PHONE 10 8.750000 218.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 108 169.750000 8487.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 71 119.000000 5950.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 195 272.000000 13600.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 254 294.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 216 955.000000 46810.0000 49.0157
INTR-T1013-INTERPRETER 9 58.750000 2888.7500 49.1702
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 154 678.000000 6780.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 113.000000 8007.3400 70.8614
OCCT-97530HM-OT SESSION BY OT ASST 1 0.750000 42.9000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 27 129.500000 9251.4800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 39 189.250000 12796.5400 67.6171
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
TRAV-TRAVS-Travel by mile 643 62072.00000 27598.4400 0.4446
Subtotal (Total Children Is Unduplicated) 739 65962.50000 187133.0800 2.8370
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Total 71317.250000 403399.4300 5.6564
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Number of Children (Unduplicated) With at Least One Service 1483
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Center 03
Flag Claims Units Chgs Paid
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R 43 32.000000 1221.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3212 2452.750000 104620.8400 0.0000
P 3801 38245.000000 92543.0500 92543.0500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 207 1458.500000 3546.3100 3546.3100
T 0 0.000000 0.0000 0.0000
8148 29129.000000 201468.2300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 15411 71317.250000 403399.4300 96089.3600