CMS/EIP Fiscal Report Center: 57
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 591 366.000000 13542.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 321 263.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 733 3234.500000 119676.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1200 3863.750000 133218.5000 34.4791
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 125 140.250000 7012.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 15.000000 1125.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 9.000000 675.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 24 24.500000 1359.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.000000 150.0000 75.0000
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 8 8.000000 408.4000 51.0500
Subtotal (Total Children Is Unduplicated) 165 214.250000 11610.2000 54.1900
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 7 13.500000 675.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 123 123.000000 6150.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 13 13.000000 650.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 2 2.000000 100.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 260 259.000000 12950.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 2 2.000000 100.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 4 4.000000 100.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 158 1083.000000 54150.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 18 27.000000 1350.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1388 11381.00000 113810.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 29.000000 2071.7600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 9.000000 514.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 12 59.500000 4250.6800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 23.000000 1314.6800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 19 105.500000 7536.9200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 142.8800 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 191 193.000000 7141.0000 37.0000
TRAV-TRAVS-Travel by mile 37 11993.00000 5336.7300 0.4450
Subtotal (Total Children Is Unduplicated) 1409 25321.50000 218344.4500 8.6229
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Total 29399.500000 363173.1500 12.3530
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Number of Children (Unduplicated) With at Least One Service 1747
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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 3 1.000000 37.0000 37.0000
D 1 0.500000 18.5000 0.0000
S 275 468.000000 9917.0400 9917.0400
H 1 0.250000 0.0000 0.0000
T 5135 24874.500000 209547.3600 209547.3600
4552 4055.250000 143653.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 9967 29399.500000 363173.1500 219501.4000