CMS/EIP Fiscal Report Center: 55
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 0.250000 9.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1 0.250000 9.2500 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 2 4.000000 200.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 55 93.481864 7011.1400 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 36 59.984266 4498.8200 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 22.133333 1660.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 11.721200 879.0900 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 1.881489 96.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 8 8.000000 408.4000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 12 11.489716 586.5500 51.0500
Subtotal (Total Children Is Unduplicated) 98 220.691868 15820.3000 71.6850
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EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 9 9.000000 450.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 55 35.500000 887.5000 25.0000
CONOP-CONOP-CONSULT, OT, PHONE 5 5.000000 125.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 8 8.000000 400.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 30 22.000000 550.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 23 127.000000 6350.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 7 11.000000 110.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 32 191.150758 13655.8100 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 2 2.000000 142.8800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 50 280.399648 16038.8600 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 6 7.000000 400.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 17 93.588327 6685.9500 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.500000 178.6000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 15 99.182821 5669.2900 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 96 570.880434 40783.6986 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 3.000000 214.3200 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 247 1468.201988 92656.1886 63.1086
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Total 1689.143856 108485.7386 64.2253
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Number of Children (Unduplicated) With at Least One Service 296
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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 0 0.000000 0.0000 0.0000
P 547 536.250000 36078.6800 36078.6800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 10 18.000000 1342.8800 0.0000
T 20 19.500000 1086.2800 1086.2800
1195 1114.393856 69926.8486 0.0000
Other 1 1.000000 51.0500 0.0000
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Total 1773 1689.143856 108485.7386 37164.9600