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
Agency Filter:EIP DEI DEIP
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
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 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 5 9.000000 675.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
Subtotal (Total Children Is Unduplicated) 8 22.000000 1508.0000 68.5455
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 46 49.500000 2475.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 50 65.500000 3275.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 20 21.000000 1050.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 21 24.250000 1212.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 51 63.500000 3175.0000 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 13 76.000000 3800.0000 50.0000
INTR-T1013-INTERPRETER 8 50.500000 2525.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 230 1220.000000 12200.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 9.000000 642.9600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 3.000000 214.3200 71.4400
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 1.000000 525.0000 525.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 13 47.000000 3357.6800 71.4400
TRAV-TRAVS-Travel by mile 296 19472.00000 8663.6000 0.4449
Subtotal (Total Children Is Unduplicated) 352 21215.75000 43172.3100 2.0349
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Total 22107.250000 71921.5600 3.2533
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Number of Children (Unduplicated) With at Least One Service 643
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Center 52
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 2 30.000000 22.9000 22.9000
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 1780 21011.750000 42149.9200 36837.4600
1486 996.500000 27852.4900 68.2400
Other 0 0.000000 0.0000 0.0000
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Total 3364 22107.250000 71921.5600 36928.6000