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
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 1123 1037.500000 38387.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1864 8539.250000 315952.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1919 9576.750000 354339.7500 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 18 13.500000 1012.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 28 24.000000 1800.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 49 59.000000 4425.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 43 42.000000 2331.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 144 107.000000 8025.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 216 171.000000 12825.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 400 464.500000 25779.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 220 216.000000 17653.9300 81.7312
OCTH-97166-OT EVAL MODERATE COMPLEXITY 13 13.000000 663.6500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 52 52.000000 2654.6000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 11 11.000000 561.5500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 20 20.000000 1021.0000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 19 19.000000 969.9500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 699 1385.000000 88416.7300 63.8388
-----------------------------------------------------------------------------------------------------------------------
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 1236 11571.00000 578550.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1227 11920.00000 119190.0000 9.9992
OCCT-97530-OT SESSION BY LICENSED OT 54 199.000000 14216.5600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 80 495.500000 28342.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 55 322.000000 22512.0200 69.9131
PHY-97110HM-PT SESSION BY PT ASST 48 316.000000 18062.5600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 142.250000 9962.3400 70.0340
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 1371 25051.75000 795099.9600 31.7383
-----------------------------------------------------------------------------------------------------------------------
Total 36013.500000 1237856.4400 34.3720
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2078
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 516 792.250000 29313.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1109 1654.250000 65618.0000 46.2500
P 7006 19138.000000 442521.0000 433617.7400
D 1 1.500000 55.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 2757 10492.500000 533615.2100 290.0000
T 0 0.000000 0.0000 0.0000
4277 3834.500000 160622.0000 0.0000
Other 45 100.500000 6111.4800 480.0000
---------------------------------------------------------
Total 15711 36013.500000 1237856.4400 434433.9900