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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 139 91.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 146 238.500000 8824.5000 37.0000
Subtotal (Total Children Is Unduplicated) 146 330.000000 8824.5000 26.7409
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 8.000000 600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 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 8 12.500000 693.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 81 123.000000 9225.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 58 103.000000 7725.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 137 223.000000 12376.5000 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) 153 500.500000 32320.2500 64.5759
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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 53157.500000 218132.1700 4.1035
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Number of Children (Unduplicated) With at Least One Service 1101
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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 577 804.000000 39782.2500 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 2972 53157.500000 218132.1700 178349.9200