CMS/EIP Fiscal Report Center: 52
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 325 147.000000 5439.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 200 134.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 319 981.000000 36132.5000 36.8323
Subtotal (Total Children Is Unduplicated) 606 1262.750000 41571.5000 32.9214
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 3 3.000000 150.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 20.000000 1500.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 18.000000 999.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 5 5.000000 250.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 27 73.000000 4765.2500 65.2774
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 129 146.250000 7287.5000 49.8291
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 11 9.250000 231.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 127 219.000000 10950.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 2 3.250000 162.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 11 9.500000 237.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 111 184.750000 9237.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 5 4.750000 237.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 25 22.500000 1125.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 3 1.500000 37.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 77 113.000000 5650.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 5 1.750000 43.7500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 33 52.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 45 137.000000 6850.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 6 7.000000 350.0000 50.0000
INTR-T1013-INTERPRETER 11 83.500000 4175.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 674 4966.000000 49660.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 28.500000 2036.0400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 4 3.750000 267.9000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 11 59.000000 3374.8000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 2 2.000000 114.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 12 31.750000 2268.2200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 22 94.250000 6733.2200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 4.750000 339.3400 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 13 9.500000 351.5000 37.0000
TRAV-TRAVS-Travel by mile 553 45394.00000 20196.6300 0.4449
Subtotal (Total Children Is Unduplicated) 738 51590.75000 131992.0500 2.5584
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Total 52926.500000 178328.8000 3.3694
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Number of Children (Unduplicated) With at Least One Service 861
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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 18.250000 17.2600 17.2600
D 0 0.000000 0.0000 0.0000
S 57 47.750000 1766.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 5659 51522.250000 135533.8800 130966.0400
1835 1338.250000 41010.9100 30.9100
Other 0 0.000000 0.0000 0.0000
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Total 7553 52926.500000 178328.8000 131014.2100