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
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 524 596.500000 22070.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 281 211.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 657 2665.750000 98632.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1085 3473.750000 120703.2500 34.7472
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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 8 9.500000 712.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 10 12.500000 937.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 15.000000 832.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 20.000000 1500.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 9.500000 712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 35 44.500000 2469.7500 55.5000
OCTH-97167-OT EVAL HIGH COMPLEXITY 8 8.000000 408.4000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 11.000000 561.5500 51.0500
Subtotal (Total Children Is Unduplicated) 191 298.000000 16537.8500 55.4961
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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 14 15.000000 750.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 306 307.000000 15350.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 141 1108.000000 55400.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1322 11704.00000 117040.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 47.000000 3357.6800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 12 58.000000 4143.5200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 12.000000 685.9200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 20 128.000000 9144.3200 71.4400
TRAV-TRAVS-Travel by mile 37 10833.00000 4820.5600 0.4450
Subtotal (Total Children Is Unduplicated) 1336 24295.00000 214842.0000 8.8431
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Total 28066.750000 352083.1000 12.5445
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Number of Children (Unduplicated) With at Least One Service 1682
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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 72 37.500000 2617.8300 2617.8300
H 0 0.000000 0.0000 0.0000
T 4656 24259.500000 213147.2700 213057.3300
3590 3762.750000 136248.0000 130.0000
Other 1 7.000000 70.0000 70.0000
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Total 8319 28066.750000 352083.1000 215875.1600