CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 Page: 1
List order: No List
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 952 908.750000 33614.5000 36.9898
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 305 231.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1107 3528.250000 130472.2500 36.9793
Subtotal (Total Children Is Unduplicated) 1188 4668.000000 164086.7500 35.1514
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 14 27.000000 1350.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 34 47.000000 2350.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 12.000000 900.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 22.000000 1650.0000 75.0000
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 7 14.000000 777.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 189 379.359734 28451.9800 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 140 286.163199 21462.2400 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 58 117.837600 8837.8200 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 48 100.000000 5550.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 20.473600 1535.5200 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 7.000000 357.3500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 31 31.000000 1582.5500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 7 7.000000 357.3500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 21 27.000000 1378.3500 51.0500
Subtotal (Total Children Is Unduplicated) 351 1104.834133 76945.4100 69.6443
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 5.000000 250.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 93 102.250000 5112.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 128 161.750000 4043.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 52 76.000000 3800.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 67 130.750000 3268.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.500000 25.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 81 87.250000 4362.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 106 114.750000 2868.7500 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 11 51.750000 1293.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 502 3512.750000 175637.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 835 7256.000000 72560.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 131 803.386195 57393.9100 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 167 934.125872 53432.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 69 433.460084 30948.5285 71.3988
PHY-97110HM-PT SESSION BY PT ASST 49 297.375259 16997.9700 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 262 1863.045492 133053.0900 71.4170
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.000000 41.6400 13.8800
TRAV-TRAVS-Travel by mile 156 7908.000000 3517.9500 0.4449
Subtotal (Total Children Is Unduplicated) 909 23741.14290 568607.5885 23.9503
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Total 29513.977035 809639.7485 27.4324
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Number of Children (Unduplicated) With at Least One Service 1236
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Center 55
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 932 731.500000 30704.5000 0.0000
P 10975 16700.706999 265852.3100 265622.0600
D 0 0.000000 0.0000 0.0000
S 1 1.303467 97.7600 0.0000
H 8 16.000000 1200.0000 0.0000
T 0 0.000000 0.0000 0.0000
12757 12064.466569 511785.1785 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 24673 29513.977035 809639.7485 265622.0600