CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 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 310 171.250000 6327.0000 36.9460
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 288 189.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 835 2477.000000 91001.5000 36.7386
Subtotal (Total Children Is Unduplicated) 904 2837.250000 97328.5000 34.3038
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 6 6.000000 300.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 17 34.500000 2497.5000 72.3913
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 16.000000 1130.0000 70.6250
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 21 45.500000 2525.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 178 378.500000 27122.1500 71.6569
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 105 232.000000 16427.3100 70.8074
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 44.000000 3300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 211 429.500000 23282.2500 54.2078
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 47.500000 3490.2200 73.4783
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 4.000000 153.1500 38.2875
OCTH-97167-OT EVAL HIGH COMPLEXITY 13 13.000000 663.6500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 42 43.000000 2100.0000 48.8372
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 22 22.000000 1123.1000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 314 1336.500000 85569.8300 64.0253
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 169 194.000000 9700.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 121 231.500000 11575.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 8 5.250000 131.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 96 182.500000 9125.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 28 26.750000 1337.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 3 1.250000 31.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 68 90.250000 4512.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 0.750000 18.7500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 65 89.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 378 2134.500000 105975.0000 49.6486
INTR-T1013-INTERPRETER 12 84.000000 4200.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 636 4955.000000 49550.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 100 419.000000 29576.5500 70.5884
OCCT-97530HM-OT SESSION BY OT ASST 38 196.250000 11225.5000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 61 424.500000 28808.1800 67.8638
PHY-97110HM-PT SESSION BY PT ASST 1 2.000000 114.3200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 220 1266.500000 87779.6500 69.3088
SPL-92508-GROUP SPL SESSION PER CHILD 3 6.750000 93.6900 13.8800
TRAV-TRAVS-Travel by mile 578 50201.00000 22336.0700 0.4449
Subtotal (Total Children Is Unduplicated) 735 60513.25000 376140.2100 6.2158
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Total 64687.000000 559038.5400 8.6422
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Number of Children (Unduplicated) With at Least One Service 979
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Center 52
Flag Claims Units Chgs Paid
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R 13 12.500000 547.0000 18.5000
U 0 0.000000 0.0000 0.0000
B 312 303.500000 14945.7300 0.0000
P 1890 1952.500000 89657.7900 86842.1000
D 0 0.000000 0.0000 0.0000
S 315 272.500000 10097.7500 0.0000
H 125 172.750000 12245.5000 74.9000
T 6177 57371.500000 199085.0100 187364.3410
3716 4601.500000 232450.5100 106.6700
Other 1 0.250000 9.2500 9.2500
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Total 12549 64687.000000 559038.5400 274415.7610