CMS/EIP Fiscal Report Center: 04
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1064 995.500000 36833.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 439 1867.750000 69106.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1240 2863.250000 105940.2500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 62 63.750000 3187.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 112 101.750000 5087.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 6.500000 487.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 12.500000 693.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 29 23.000000 1725.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 44 35.000000 2625.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 195 161.000000 8935.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 47 36.500000 2737.5000 75.0000
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-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 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 13 13.000000 663.6500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 413 479.000000 27613.9000 57.6491
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 33 83.000000 4150.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 227 1969.000000 98450.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1227 11920.00000 119190.0000 9.9992
OCCT-97530-OT SESSION BY LICENSED OT 12 48.000000 3429.1200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 21 120.500000 6892.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 10 70.750000 4697.1800 66.3912
PHY-97110HM-PT SESSION BY PT ASST 4 26.000000 1486.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 48.750000 3482.7000 71.4400
Subtotal (Total Children Is Unduplicated) 1278 14288.00000 241877.7600 16.9287
-----------------------------------------------------------------------------------------------------------------------
Total 17630.250000 375431.9100 21.2948
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1787
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 3856 14266.000000 242281.9100 242281.9100
D 1 1.500000 55.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 10 29.000000 290.0000 290.0000
T 0 0.000000 0.0000 0.0000
3760 3317.750000 132324.5000 0.0000
Other 4 16.000000 480.0000 480.0000
---------------------------------------------------------
Total 7631 17630.250000 375431.9100 243051.9100