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
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 450 200.500000 7418.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 242 185.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 659 2652.250000 98133.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1048 3037.750000 105551.7500 34.7467
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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 2 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.500000 138.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 29.000000 2175.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 11.000000 825.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 35 41.000000 2275.5000 55.5000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 11 11.000000 561.5500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 11 11.000000 561.5500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 12 12.000000 612.6000 51.0500
Subtotal (Total Children Is Unduplicated) 169 282.500000 15463.5000 54.7381
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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 90 90.000000 4500.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 195 195.000000 9750.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 163 1180.000000 59000.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1376 11325.00000 113250.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 51.000000 3643.4400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.500000 85.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 10 53.500000 3822.0400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 21.000000 1200.3600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 18 107.000000 7644.0800 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.500000 85.8000 57.2000
TRAV-TRAVS-Travel by mile 38 10853.00000 4829.4400 0.4450
Subtotal (Total Children Is Unduplicated) 1388 23883.50000 208060.9600 8.7115
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Total 27203.750000 329076.2100 12.0967
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Number of Children (Unduplicated) With at Least One Service 1716
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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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 174 88.000000 6245.9400 6245.9400
H 0 0.000000 0.0000 0.0000
T 4307 23823.500000 203163.9100 203163.9200
3393 3292.250000 119666.3600 387.8600
Other 0 0.000000 0.0000 0.0000
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Total 7874 27203.750000 329076.2100 209797.7200