CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
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 412 171.250000 6336.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 403 365.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 458 1164.750000 43095.7500 37.0000
Subtotal (Total Children Is Unduplicated) 794 1701.750000 49432.0000 29.0477
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 22 33.000000 2475.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 10.000000 750.0000 75.0000
Subtotal (Total Children Is Unduplicated) 31 46.500000 3458.2500 74.3710
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 2.000000 100.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 3.250000 162.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 3 1.000000 50.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.250000 6.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 11.000000 550.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 8 21.000000 210.0000 10.0000
PHY-97110-PT SESSION BY LICENSED PT 3 22.750000 1625.2600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 7.250000 517.9400 71.4400
TRAV-TRAVS-Travel by mile 6 293.000000 130.3500 0.4449
Subtotal (Total Children Is Unduplicated) 19 362.500000 3377.3000 9.3167
-----------------------------------------------------------------------------------------------------------------------
Total 2110.750000 56267.5500 26.6576
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 799
-----------------------------------------------------------------------------------------------------------------------
Center 05
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 92 405.000000 6546.2300 6546.2300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2865 1705.750000 49721.3200 214.3200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2957 2110.750000 56267.5500 6760.5500