CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 67 42.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 69 120.500000 4458.5000 37.0000
Subtotal (Total Children Is Unduplicated) 69 162.500000 4458.5000 27.4369
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 54.000000 4050.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 35 64.500000 4837.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 66 115.500000 6410.2500 55.5000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 3.000000 150.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 5 22.000000 1100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 76 266.500000 17051.7500 63.9841
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 11 14.750000 737.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 3.000000 75.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 3 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 246 1080.000000 53851.0100 49.8620
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 3.000000 30.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 32 126.000000 9001.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 61 219.000000 15645.3600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 159 1061.250000 75815.7000 71.4400
TRAV-TRAVS-Travel by mile 946 49817.00000 21681.4100 0.4352
Subtotal (Total Children Is Unduplicated) 978 52327.00000 176987.4200 3.3823
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Total 52756.000000 198497.6700 3.7626
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Number of Children (Unduplicated) With at Least One Service 1024
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Center 09
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 2395 52353.500000 178349.9200 178349.9200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 274 402.500000 20147.7500 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2669 52756.000000 198497.6700 178349.9200