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
Agency Filter:EXT
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 23 29.000000 1073.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 14 30.500000 1128.5000 37.0000
Subtotal (Total Children Is Unduplicated) 36 59.500000 2201.5000 37.0000
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Screening, Eval, and Assessment,Class #02
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 3 3.000000 153.1500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 23 23.000000 1174.1500 51.0500
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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
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Total 14370.500000 245253.4100 17.0664
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Number of Children (Unduplicated) With at Least One Service 1298
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Center 04
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 3856 14266.000000 242281.9100 242281.9100
D 0 0.000000 0.0000 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
95 59.500000 2201.5000 0.0000
Other 4 16.000000 480.0000 480.0000
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Total 3965 14370.500000 245253.4100 243051.9100