CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 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 1495 885.000000 32745.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 488 372.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 899 2121.250000 78473.7500 36.9941
Subtotal (Total Children Is Unduplicated) 1891 3378.500000 111218.7500 32.9196
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 39 72.000000 3600.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 19.500000 1462.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 22.000000 1650.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 23.000000 1276.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 20.500000 1537.5000 75.0000
Subtotal (Total Children Is Unduplicated) 69 160.500000 9789.0000 60.9907
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 709.2800 709.2800
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 103 100.750000 4887.5000 48.5112
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 10 9.000000 225.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 6 8.500000 350.0000 41.1765
CONIP-CONIP-CONSULT, ITDS PHONE 17 19.000000 475.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 3.000000 150.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 10 12.500000 312.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 4.000000 200.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 5 5.000000 250.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 5 7.000000 150.0000 21.4286
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 411 3170.500000 158212.5000 49.9014
INTR-T1013-INTERPRETER 12 34.000000 2372.0000 69.7647
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1383 11816.00000 117680.0000 9.9594
OCCT-97530-OT SESSION BY LICENSED OT 16 44.000000 3126.4900 71.0566
OCCT-97530HM-OT SESSION BY OT ASST 4 19.500000 1115.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 17 54.000000 3857.7600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 9.750000 557.3100 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 204.750000 14484.4600 70.7422
Subtotal (Total Children Is Unduplicated) 1400 15522.25000 309115.2000 19.9143
-----------------------------------------------------------------------------------------------------------------------
Total 19061.250000 430122.9500 22.5653
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2234
-----------------------------------------------------------------------------------------------------------------------
Center 06
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 9909 9795.250000 198967.8500 198967.8500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
12298 9266.000000 231155.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22207 19061.250000 430122.9500 198967.8500