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
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 620 945.500000 34965.0000 36.9804
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 190 214.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 281 848.500000 31311.2500 36.9019
Subtotal (Total Children Is Unduplicated) 688 2008.250000 66276.2500 33.0020
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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 1 1.000000 75.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 55 57.000000 4223.9500 74.1044
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 9.000000 675.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 7.000000 525.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 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 58 59.000000 3252.2500 55.1229
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 13.500000 900.0000 66.6667
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 13 13.000000 663.6500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 151 229.500000 14078.5000 61.3442
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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 52 305.500000 15275.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 3 2.500000 125.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 575 3538.000000 35263.0000 9.9669
OCCT-97530-OT SESSION BY LICENSED OT 29 103.000000 7134.0400 69.2625
OCCT-97530HM-OT SESSION BY OT ASST 39 202.750000 11597.3000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 3 9.750000 557.7000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 25 93.250000 6608.2000 70.8654
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 88 377.750000 26625.6800 70.4849
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 6.000000 428.6400 71.4400
TRAV-TRAVS-Travel by mile 19 3787.000000 1685.0100 0.4449
Subtotal (Total Children Is Unduplicated) 589 8438.500000 106163.4600 12.5808
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Total 10676.250000 186518.2100 17.4704
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Number of Children (Unduplicated) With at Least One Service 868
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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 0 0.000000 0.0000 0.0000
P 1576 8485.250000 109808.7600 109808.7600
D 0 0.000000 0.0000 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
2984 2190.000000 76634.4500 285.7600
Other 1 1.000000 75.0000 75.0000
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Total 4561 10676.250000 186518.2100 110169.5200