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
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 310 171.250000 6327.0000 36.9460
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 287 188.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 324 929.750000 34160.2500 36.7413
Subtotal (Total Children Is Unduplicated) 647 1289.250000 40487.2500 31.4037
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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 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 13.500000 1012.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 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 8 16.000000 888.0000 55.5000
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
SCREEN-T1023-SCREENING 3 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 25 62.500000 3937.7000 63.0032
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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 120 228.500000 11425.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 8 5.250000 131.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 96 180.500000 9025.0000 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 89.250000 4462.5000 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 33 128.750000 6437.5000 50.0000
INTR-T1013-INTERPRETER 12 84.000000 4200.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 636 4953.000000 49530.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 40.250000 2875.4600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 12 57.000000 3260.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 9 29.500000 1927.4800 65.3383
PHY-97110HM-PT SESSION BY PT ASST 1 2.000000 114.3200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 23 108.500000 7751.2400 71.4400
TRAV-TRAVS-Travel by mile 578 50201.00000 22336.0700 0.4449
Subtotal (Total Children Is Unduplicated) 735 56421.75000 134613.7200 2.3858
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Total 57773.500000 179038.6700 3.0990
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Number of Children (Unduplicated) With at Least One Service 884
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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 2 50.000000 93.2400 93.2400
D 0 0.000000 0.0000 0.0000
S 69 58.250000 2072.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 5469 56292.500000 136911.1300 131785.9810
1972 1372.750000 39962.3000 106.6700
Other 0 0.000000 0.0000 0.0000
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Total 7512 57773.500000 179038.6700 131985.8910