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: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 1092 1066.500000 39451.2500 36.9913
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 325 248.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1250 4072.250000 150600.2500 36.9821
Subtotal (Total Children Is Unduplicated) 1336 5386.750000 190051.5000 35.2813
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 19 43.000000 2150.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 37 51.000000 2550.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 18.000000 1350.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 26.000000 1950.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 20.000000 1110.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 270 540.026401 40501.9800 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 216 446.163199 33462.2400 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 83 169.837600 12737.8200 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 83 170.000000 9435.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 33.806933 2535.5200 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) 478 1598.834133 112013.4100 70.0594
-----------------------------------------------------------------------------------------------------------------------
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 503 3514.750000 175737.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 836 7258.000000 72580.0000 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) 910 23745.14290 568727.5885 23.9513
-----------------------------------------------------------------------------------------------------------------------
Total 30730.727035 870792.4985 28.3362
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1385
-----------------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1026 863.500000 36804.5000 0.0000
P 11300 17114.823666 285139.5600 284870.0600
D 0 0.000000 0.0000 0.0000
S 1 1.303467 97.7600 0.0000
H 13 26.000000 1950.0000 0.0000
T 0 0.000000 0.0000 0.0000
13353 12725.099902 546800.6785 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 25693 30730.727035 870792.4985 284870.0600