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: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 1899 4481.500000 165815.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 686 617.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 876 3217.750000 119056.7500 37.0000
Subtotal (Total Children Is Unduplicated) 2109 8316.250000 284872.2500 34.2549
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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 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 45 78.000000 5850.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 48.000000 3600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 62 109.500000 8212.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 44 78.500000 4356.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 62.500000 4687.5000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 4 30.000000 1500.0000 50.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 272 674.000000 41873.8500 62.1274
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 153 267.500000 13375.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 48 43.750000 1093.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 16 21.500000 1075.0000 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 420 2317.250000 115862.5000 50.0000
INTR-T1013-INTERPRETER 87 169.750000 8487.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 78 546.000000 5460.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 63 309.000000 22074.9600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 82 425.500000 30397.7200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 201 1328.000000 94872.3200 71.4400
TRAV-TRAVS-Travel by mile 1383 105231.0000 45989.5700 0.4370
Subtotal (Total Children Is Unduplicated) 1624 111083.7500 342650.8200 3.0846
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Total 120074.000000 669396.9200 5.5749
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Number of Children (Unduplicated) With at Least One Service 2432
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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 15394 114321.500000 648460.3200 648460.3200
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
300 5738.500000 19886.6000 0.0000
Other 9 14.000000 1050.0000 0.0000
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Total 15703 120074.000000 669396.9200 648460.3200