CMS/EIP Fiscal Report Center: 52
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 3.000000 111.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1 3.000000 111.0000 37.0000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 2 2.000000 100.0000 50.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 13 26.000000 1570.2000 60.3923
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 127 137.750000 6887.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 94 161.000000 8050.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 7 4.750000 118.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 75 154.750000 7737.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 12 12.250000 612.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 30 37.250000 1862.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.500000 12.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 23 79.750000 3987.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 533 3716.000000 37160.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 34.250000 2446.8200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 12 57.000000 3260.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 9 29.500000 1927.4800 65.3383
PHY-97110HM-PT SESSION BY PT ASST 1 2.000000 114.3200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 17 88.000000 6286.7200 71.4400
TRAV-TRAVS-Travel by mile 395 28545.00000 12700.4200 0.4449
Subtotal (Total Children Is Unduplicated) 576 33062.25000 93227.4100 2.8198
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Total 33091.250000 94908.6100 2.8681
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Number of Children (Unduplicated) With at Least One Service 576
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Center 52
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 2 50.000000 93.2400 93.2400
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 3692 33029.250000 94491.4900 94491.4910
6 12.000000 323.8800 70.0000
Other 0 0.000000 0.0000 0.0000
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Total 3700 33091.250000 94908.6100 94654.7310