CMS/EIP Fiscal Report Center: 57
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 524 596.500000 22070.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 281 211.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1667 6767.500000 250397.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1699 7575.500000 272468.0000 35.9670
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 132 165.000000 8250.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 33 39.500000 2962.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 63 75.000000 5625.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 41 52.500000 2913.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 256 279.000000 20905.5000 74.9301
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 20.500000 1537.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 74 83.500000 6262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 407 499.500000 27722.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 9.000000 675.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 29 29.000000 1480.4500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 10 11.000000 561.5500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 22 23.000000 1174.1500 51.0500
Subtotal (Total Children Is Unduplicated) 607 1286.500000 80070.1500 62.2387
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 4.000000 200.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 79 79.000000 3950.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 15 16.000000 800.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 316 317.000000 15850.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 21 914.000000 22850.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1316 11159.00000 557950.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1325 11803.00000 118030.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 32 146.750000 10483.8200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 37 166.000000 11859.0400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 15 103.000000 5887.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 55 326.000000 23253.7200 71.3304
TRAV-TRAVS-Travel by mile 37 10833.00000 4820.5600 0.4450
Subtotal (Total Children Is Unduplicated) 1368 35866.75000 775934.6200 21.6338
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Total 44728.750000 1128472.7700 25.2292
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Number of Children (Unduplicated) With at Least One Service 1883
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Center 57
Flag Claims Units Chgs Paid
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R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 379 458.250000 17763.7500 55.0000
P 3732 4288.250000 176202.8600 172829.6300
D 0 0.000000 0.0000 0.0000
S 107 58.000000 4021.1800 4021.1800
H 12 14.500000 1087.5000 0.0000
T 5571 27479.000000 374522.5100 374432.5700
6127 12273.750000 551079.7400 392623.3210
Other 102 156.000000 3758.2300 3758.2300
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Total 16031 44728.750000 1128472.7700 947719.9310