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
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 1899 4481.500000 165815.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 824 708.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2149 7729.250000 285889.7500 36.9880
Subtotal (Total Children Is Unduplicated) 2364 12919.25000 451705.2500 34.9637
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 123 250.000000 12500.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 21.000000 1575.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 19.000000 1425.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 10.000000 750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 12.000000 900.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 23 40.000000 2220.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 281 456.500000 33487.3500 73.3567
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 190 328.500000 24441.1700 74.4023
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 180 304.500000 22724.5000 74.6289
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 418 720.500000 39827.7500 55.2779
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 188 302.000000 22154.4000 73.3589
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 3.000000 150.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 5 52.000000 2600.0000 50.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 10.000000 510.5000 51.0500
Subtotal (Total Children Is Unduplicated) 787 2533.000000 165469.8700 65.3256
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 351.7400 351.7400
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 163 282.250000 14112.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 51 46.750000 1168.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 19 24.500000 1225.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 14 15.000000 750.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 23 32.000000 1600.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 27 31.000000 1550.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 3 1.500000 37.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 265 344.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1298 8872.500000 443430.0100 49.9780
INTR-T1013-INTERPRETER 87 169.750000 8487.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 79 549.000000 5490.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 149 992.500000 70106.8400 70.6366
OCCT-97530HM-OT SESSION BY OT ASST 2 9.000000 344.5200 38.2800
PHY-97110-PT SESSION BY LICENSED PT 210 1558.000000 109940.8300 70.5654
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 510 4325.000000 305585.6000 70.6556
TRAV-TRAVS-Travel by mile 1651 155048.0000 67670.9800 0.4365
Subtotal (Total Children Is Unduplicated) 1882 172302.7500 1031876.7700 5.9887
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Total 187755.000000 1649051.8900 8.7830
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Number of Children (Unduplicated) With at Least One Service 2611
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Center 09
Flag Claims Units Chgs Paid
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R 2 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 182 191.250000 7686.7600 120.2500
P 22607 172407.750000 1081152.6400 1081927.4000
D 15 14.500000 922.4600 0.0000
S 0 0.000000 0.0000 0.0000
H 577 804.000000 39782.2500 0.0000
T 3 4.500000 240.5000 425.5000
2950 13882.500000 486376.2800 0.0000
Other 267 450.000000 32872.5000 0.0000
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Total 26603 187755.000000 1649051.8900 1082473.1500