CMS/EIP Fiscal Report Center: 51
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 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 620 945.500000 34965.0000 36.9804
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 190 214.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 649 1863.000000 68699.7500 36.8759
Subtotal (Total Children Is Unduplicated) 767 3022.750000 103664.7500 34.2948
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 47 47.000000 2350.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 5.000000 375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 105 110.000000 8050.9500 73.1905
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 13 13.000000 975.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 20.000000 1500.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 5.000000 375.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 114 116.500000 6443.5000 55.3090
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 27 29.500000 2100.0000 71.1864
OCTH-97165-OT EVAL LOW COMPLEXITY 6 6.000000 306.3000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 28 29.000000 1448.7800 49.9579
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 18 19.000000 969.9500 51.0500
Subtotal (Total Children Is Unduplicated) 260 427.000000 26521.8800 62.1121
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 313.8900 156.9450
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 7 7.000000 350.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 189 1108.500000 55425.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 6 10.500000 525.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 575 3538.000000 35263.0000 9.9669
OCCT-97530-OT SESSION BY LICENSED OT 113 448.500000 31340.4900 69.8785
OCCT-97530HM-OT SESSION BY OT ASST 120 553.750000 31617.3000 57.0967
OCCT-97530HMGT-OT SESSION BY OT ASST 3 9.750000 557.7000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 66 250.750000 17860.0000 71.2263
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 263 1296.750000 92047.4600 70.9832
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 14.500000 978.3200 67.4703
TRAV-TRAVS-Travel by mile 19 3787.000000 1685.0100 0.4449
Subtotal (Total Children Is Unduplicated) 618 11031.00000 268163.1700 24.3100
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Total 14480.750000 398349.8000 27.5089
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Number of Children (Unduplicated) With at Least One Service 918
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Center 51
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 1114 828.750000 34664.8300 0.0000
P 2168 9397.250000 162565.7000 162416.9500
D 14 12.500000 538.0000 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
3711 4240.250000 200434.8300 285.7600
Other 2 2.000000 146.4400 75.0000
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Total 7009 14480.750000 398349.8000 162777.7100