CMS/EIP Fiscal Report Center: 06
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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 1614 1026.500000 37980.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 908 671.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 911 2346.750000 86829.7500 37.0000
Subtotal (Total Children Is Unduplicated) 2020 4044.250000 124810.2500 30.8612
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 29 56.000000 2800.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 32 51.000000 3825.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 18.000000 1350.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 23.500000 1762.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 29 47.500000 2636.2500 55.5000
Subtotal (Total Children Is Unduplicated) 73 196.000000 12373.7500 63.1314
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 118 119.250000 5850.0000 49.0566
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 13 8.750000 218.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 5 6.500000 325.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 13 16.000000 400.0000 25.0000
CONOP-CONOP-CONSULT, OT, PHONE 4 4.000000 100.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 6 7.500000 375.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 8 10.500000 262.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 402 2893.000000 143650.0000 49.6543
INTR-T1013-INTERPRETER 2 12.000000 875.5000 72.9583
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1357 10899.00000 108850.0000 9.9872
OCCT-97530-OT SESSION BY LICENSED OT 12 31.500000 2250.3600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 8.500000 486.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 15 44.750000 3196.9400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 53 221.250000 15091.7000 68.2111
SPL-92508-GROUP SPL SESSION PER CHILD 3 7.500000 83.2800 11.1040
Subtotal (Total Children Is Unduplicated) 1370 14290.00000 282015.2300 19.7351
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Total 18530.250000 419199.2300 22.6224
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Number of Children (Unduplicated) With at Least One Service 2360
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Center 06
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 10397 10223.750000 202344.4600 202344.4600
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
11796 8306.500000 216854.7700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 22193 18530.250000 419199.2300 202344.4600