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
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 1063 1022.750000 37841.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 448 2029.000000 75073.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1276 3051.750000 112914.7500 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 1 0.500000 37.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 7.000000 525.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 22 14.000000 777.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 37 30.000000 2250.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 47 40.000000 3000.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 221 176.000000 9768.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 21.500000 1612.5000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 13 13.000000 663.6500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 390 441.000000 25698.3500 58.2729
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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 228 1802.000000 90100.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 25 28.000000 1400.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1193 11133.00000 111330.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 34.500000 2264.6800 65.6429
OCCT-97530HM-OT SESSION BY OT ASST 22 133.750000 7536.1000 56.3447
OCCT-97530HMGT-OT SESSION BY OT ASST 1 9.000000 514.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 12 43.000000 2584.3600 60.1014
PHY-97110HM-PT SESSION BY PT ASST 4 21.000000 1200.3600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 32.500000 2321.8000 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 3 3.000000 111.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1242 13303.75000 222563.1000 16.7294
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Total 16796.500000 361176.2000 21.5031
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Number of Children (Unduplicated) With at Least One Service 1834
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Center 04
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 3854 13009.750000 218723.9000 218723.9000
D 1 1.000000 55.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 81 243.000000 2990.0000 2920.0000
T 0 0.000000 0.0000 0.0000
3886 3475.750000 137740.8000 0.0000
Other 24 67.000000 1666.0000 1666.0000
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Total 7846 16796.500000 361176.2000 223309.9000