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
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 726 448.250000 16585.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 411 385.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 510 1366.500000 50495.7500 36.9526
Subtotal (Total Children Is Unduplicated) 1058 2200.500000 67081.0000 30.4844
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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 16 27.500000 2062.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 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 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 18.500000 1026.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 101 181.000000 13575.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 37 61.000000 4575.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 22.500000 1687.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 78 130.500000 7242.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 38.000000 2850.0000 75.0000
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 47 58.000000 2900.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 268 666.000000 42883.3000 64.3893
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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 209 917.250000 45022.5000 49.0842
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 14 53.500000 3822.0400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 22 108.500000 7751.2400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 31 140.750000 9921.3400 70.4891
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) 737 65795.00000 176741.9400 2.6863
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Total 68661.500000 286706.2400 4.1756
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Number of Children (Unduplicated) With at Least One Service 1351
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Center 03
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 3731 38174.500000 87975.2100 87975.2100
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
8061 29028.500000 195184.7200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11999 68661.500000 286706.2400 91521.5200