CMS/EIP Fiscal Report Center: 57
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 Page: 1
List order: No List
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 450 200.500000 7418.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 242 185.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1652 6754.750000 249925.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1673 7140.250000 257344.2500 36.0414
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 111 161.500000 8075.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 26 27.500000 2062.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 31 38.000000 2109.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 286 307.000000 23025.0000 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 123 144.000000 10800.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 402 477.500000 26501.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 32 36.000000 1837.8000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 31 32.000000 1633.6000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 55 57.000000 2909.8500 51.0500
Subtotal (Total Children Is Unduplicated) 620 1300.500000 80430.0500 61.8455
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 3.000000 150.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 94 94.000000 4700.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 200 200.000000 10000.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 23 826.000000 20650.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1366 10864.00000 543200.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1377 11357.00000 113570.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 66 352.000000 25146.8800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 52 224.250000 12827.1000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 49 237.750000 16984.8600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 46 246.000000 14061.3600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 73 347.500000 24825.4000 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 56 278.250000 15747.3000 56.5941
TRAV-TRAVS-Travel by mile 38 10853.00000 4829.4400 0.4450
Subtotal (Total Children Is Unduplicated) 1468 35884.75000 806792.3400 22.4829
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Total 44325.500000 1144566.6400 25.8219
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Number of Children (Unduplicated) With at Least One Service 1882
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Center 57
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 222 266.000000 11344.7500 18.5000
P 3873 4468.000000 181763.4800 178005.8600
D 0 0.000000 0.0000 0.0000
S 183 92.500000 6567.4200 6567.4200
H 0 0.000000 0.0000 0.0000
T 5247 27065.500000 365871.5500 365871.5600
6271 12384.500000 577820.8400 436812.4300
Other 31 49.000000 1198.6000 1198.6000
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Total 15827 44325.500000 1144566.6400 988474.3700