CMS/EIP Fiscal Report Center: 52
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 272 132.500000 4884.0000 36.8604
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 186 125.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 245 612.000000 22357.2500 36.5315
Subtotal (Total Children Is Unduplicated) 508 869.500000 27241.2500 31.3298
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 70.4000 70.4000
EXIT-EXIT-EXIT ASSESSMENT 3 3.000000 150.0000 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 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 11.000000 825.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 13 37.000000 2491.5000 67.3378
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 118 131.750000 6587.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 1.500000 37.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 122 187.250000 9362.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 6 3.750000 93.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 111 242.500000 12125.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.250000 6.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 35 37.250000 1862.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 76 92.000000 4600.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 0.750000 18.7500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 78 111.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 28 140.000000 7000.0000 50.0000
INTR-T1013-INTERPRETER 8 50.500000 2525.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 631 4740.000000 47400.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 56.000000 3994.9000 71.3375
OCCT-97530HM-OT SESSION BY OT ASST 12 59.000000 3374.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 14 54.750000 3911.3400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 1.000000 525.0000 525.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 148.750000 10429.2400 70.1125
TRAV-TRAVS-Travel by mile 534 47130.00000 20969.2800 0.4449
Subtotal (Total Children Is Unduplicated) 692 53190.25000 134905.4700 2.5363
-----------------------------------------------------------------------------------------------------------------------
Total 54096.750000 164638.2200 3.0434
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 795
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 3 30.250000 35.4000 35.4000
D 0 0.000000 0.0000 0.0000
S 96 69.000000 1896.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 5265 52951.000000 134658.0600 129345.6000
1495 1046.500000 28048.5100 264.2600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6859 54096.750000 164638.2200 129645.2600