CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 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 1063 1022.750000 37841.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1844 8380.750000 310087.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1897 9403.500000 347929.5000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 32 30.750000 1537.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 90 90.250000 4512.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 13.000000 975.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 22 18.000000 1350.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 38 52.000000 4753.4600 91.4127
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 45 60.000000 3330.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 132 98.000000 7350.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 173 134.500000 10087.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 350 400.500000 22141.7500 55.2853
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 193 192.500000 19756.7900 102.6327
OCTH-97166-OT EVAL MODERATE COMPLEXITY 6 6.000000 306.3000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 33 33.000000 1602.6900 48.5664
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 24 24.000000 1225.2000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 19 19.000000 969.9500 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 20 20.000000 1021.0000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 7 7.000000 357.3500 51.0500
Subtotal (Total Children Is Unduplicated) 597 1200.500000 81379.0900 67.7877
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 26 64.000000 3200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1181 10666.00000 533220.0000 49.9925
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 61 81.000000 4050.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1193 11133.00000 111330.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 50 199.000000 13357.7800 67.1245
OCCT-97530GT-OT SESSION BY LICENSED OT 2 3.500000 125.0400 35.7257
OCCT-97530HM-OT SESSION BY OT ASST 85 503.250000 28671.5000 56.9727
OCCT-97530HMGT-OT SESSION BY OT ASST 3 12.000000 686.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 50 283.500000 19741.8800 69.6363
PHY-97110GT-PT SESSION BY LICENSED PT 3 6.000000 379.5900 63.2650
PHY-97110HM-PT SESSION BY PT ASST 47 369.000000 21092.0400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 175.500000 12083.2400 68.8504
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 3 3.000000 111.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1335 23498.75000 748048.4700 31.8335
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Total 34102.750000 1177357.0600 34.5238
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Number of Children (Unduplicated) With at Least One Service 2049
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Center 04
Flag Claims Units Chgs Paid
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R 37 50.750000 1877.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1268 1802.000000 70009.5000 101.7500
P 6756 17554.250000 408915.6400 398974.9300
D 2 2.000000 130.5000 0.0000
S 2 4.000000 148.0000 0.0000
H 2903 10028.500000 501926.4200 2920.0000
T 0 0.000000 0.0000 0.0000
4629 4424.250000 181543.2600 81.4600
Other 99 237.000000 12805.9900 1666.0000
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Total 15696 34102.750000 1177357.0600 403744.1400