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
Payclass Filters:GR
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 368 1139.250000 42152.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1187 2453.750000 81603.5000 33.2566
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 19 35.000000 1750.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 36 50.000000 2500.0000 50.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 32 52.205200 3915.3900 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 23 43.740933 3280.5700 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 13.369467 1002.7100 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 24 50.000000 2775.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 10.503466 787.7600 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 4.020568 205.2500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 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 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 126 267.839634 16685.0300 62.2949
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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 70 76.250000 3812.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 126 155.750000 3893.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 49 71.000000 3550.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 65 124.750000 3118.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.500000 25.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 59 64.250000 3212.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 104 108.250000 2706.2500 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 33.000000 825.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 130 865.400000 43270.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 836 7258.000000 72580.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 33 139.025608 9931.9900 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 21 100.832344 5767.6100 57.2000
PHY-97110-PT SESSION BY LICENSED PT 14 62.975502 4498.9700 71.4400
PHY-97110HM-PT SESSION BY PT ASST 8 46.944542 2683.3500 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 58 288.234601 20591.4800 71.4400
TRAV-TRAVS-Travel by mile 156 7908.000000 3517.9500 0.4449
Subtotal (Total Children Is Unduplicated) 871 17308.16260 184235.1000 10.6444
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Total 20029.752231 282523.6300 14.1052
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Number of Children (Unduplicated) With at Least One Service 1337
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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 1 0.250000 0.0000 0.0000
P 7657 13838.073666 135169.5500 135169.5500
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
6987 6191.428565 147354.0800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 14645 20029.752231 282523.6300 135169.5500