CMS/EIP Fiscal Report Center: 10
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:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 48 53.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 63 254.750000 9425.7500 37.0000
Subtotal (Total Children Is Unduplicated) 88 308.250000 9425.7500 30.5783
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 37.500000 2812.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 17.000000 1275.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.000000 525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 40.500000 2247.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
Subtotal (Total Children Is Unduplicated) 30 118.500000 7980.7500 67.3481
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 10.000000 500.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 7.000000 350.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 18.000000 180.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 8.000000 571.5200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 10.000000 714.4000 71.4400
Subtotal (Total Children Is Unduplicated) 2 55.000000 2415.9200 43.9258
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Total 481.750000 19822.4200 41.1467
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Number of Children (Unduplicated) With at Least One Service 103
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Center 10
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 15 55.000000 2415.9200 2415.9200
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
356 393.250000 15167.0000 0.0000
Other 17 33.500000 2239.5000 0.0000
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Total 388 481.750000 19822.4200 2415.9200