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: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 289 143.500000 5291.0000 36.8711
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 213 139.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 273 724.500000 26510.5000 36.5914
Subtotal (Total Children Is Unduplicated) 560 1007.750000 31801.5000 31.5569
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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 8 15.000000 1125.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 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 5 10.000000 555.0000 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) 15 45.000000 3052.5000 67.8333
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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 79 111.750000 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 634 4748.000000 47480.0000 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 578 48155.00000 21425.2700 0.4449
Subtotal (Total Children Is Unduplicated) 736 54223.75000 135441.4600 2.4978
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Total 55276.500000 170295.4600 3.0808
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Number of Children (Unduplicated) With at Least One Service 853
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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 3 30.250000 35.4000 35.4000
D 0 0.000000 0.0000 0.0000
S 123 92.000000 2599.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 5349 53992.000000 135755.0500 130382.5900
1604 1162.250000 31905.7600 264.2600
Other 0 0.000000 0.0000 0.0000
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Total 7079 55276.500000 170295.4600 130682.2500