CMS/EIP Fiscal Report Center: 05
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 451 187.750000 6946.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 448 407.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1162 2951.250000 109196.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1195 3546.500000 116143.0000 32.7486
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 11.500000 862.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 7.500000 562.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 8.000000 600.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 33 42.000000 2331.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 53 80.500000 6037.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 5.500000 412.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 99 147.000000 11025.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 61 91.500000 5078.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 45.500000 3412.5000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 1.000000 50.0000 50.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 112.5500 37.5167
OCTH-97167-OT EVAL HIGH COMPLEXITY 6 6.000000 224.4400 37.4067
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 16 16.000000 816.8000 51.0500
Subtotal (Total Children Is Unduplicated) 242 472.500000 31944.3400 67.6071
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 95 105.250000 5113.8300 48.5875
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 0.750000 18.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 83 62.000000 3100.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 11 4.500000 112.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 28 19.500000 975.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 4 2.000000 50.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 27 18.750000 937.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 50 34.250000 1712.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 4 2.500000 62.5000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 16 65.500000 1637.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 260 1423.750000 71187.5000 50.0000
INTR-T1013-INTERPRETER 16 69.000000 3450.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 713 4615.000000 46150.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 34 200.000000 12127.7400 60.6387
PHY-97110-PT SESSION BY LICENSED PT 46 227.750000 13197.4400 57.9470
PHY-97110HM-PT SESSION BY PT ASST 1 6.000000 342.9600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 109 558.250000 36406.9100 65.2161
TRAV-TRAVS-Travel by mile 749 70934.00000 31551.4300 0.4448
Subtotal (Total Children Is Unduplicated) 786 78349.75000 228159.0600 2.9121
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Total 82368.750000 376246.4000 4.5678
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Number of Children (Unduplicated) With at Least One Service 1274
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Center 05
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 2610 1773.500000 69898.1700 42287.0000
P 6637 70803.750000 228018.5500 228018.5500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3907 9791.500000 78329.6800 23041.4300
Other 0 0.000000 0.0000 0.0000
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Total 13154 82368.750000 376246.4000 293346.9800