CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 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 128 86.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 140 232.500000 8602.5000 37.0000
Subtotal (Total Children Is Unduplicated) 140 318.500000 8602.5000 27.0094
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 13.500000 1012.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 13.500000 749.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 67 105.500000 7912.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.500000 187.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 64 114.500000 8587.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 127 213.000000 11766.0000 55.2394
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.000000 222.0000 55.5000
Subtotal (Total Children Is Unduplicated) 141 468.000000 30549.7500 65.2772
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 13 18.000000 900.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 2.500000 62.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 2.000000 100.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 200 917.000000 45850.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 41 57.000000 2850.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 32 185.000000 13216.4000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 7 10.000000 714.4000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 52 314.000000 22432.1600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 3 11.000000 785.8400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 164 1005.500000 71832.9200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 31 76.000000 5429.4400 71.4400
TRAV-TRAVS-Travel by mile 781 41844.00000 18183.7200 0.4346
Subtotal (Total Children Is Unduplicated) 816 44443.00000 182407.3800 4.1043
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Total 45229.500000 221559.6300 4.8986
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Number of Children (Unduplicated) With at Least One Service 940
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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 2280 43870.000000 177599.0600 177599.0600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 550 786.500000 39152.2500 0.0000
T 0 0.000000 0.0000 0.0000
41 573.000000 4808.3200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2871 45229.500000 221559.6300 177599.0600