CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/21/2020 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 875 1004.500000 37166.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 409 1893.000000 70041.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1092 2897.500000 107207.5000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 42 63.250000 3162.5000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 31 44.500000 2469.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 10 13.000000 975.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 16 17.000000 1275.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 80 122.000000 6771.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 20.500000 1537.5000 75.0000
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 161 291.750000 16957.4500 58.1232
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EI Services,Class #03
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 9 15.250000 381.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 61 351.000000 17550.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 118 1041.500000 52000.0000 49.9280
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 513 3496.000000 34960.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 5.000000 357.2000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 4 18.000000 1029.6000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 9 29.500000 1687.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 4 16.000000 1143.0400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 5.000000 357.2000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 11.000000 628.7600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 9.000000 642.9600 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 5 15.000000 555.0000 37.0000
Subtotal (Total Children Is Unduplicated) 631 5012.250000 111292.4100 22.2041
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Total 8201.500000 235457.3600 28.7091
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Number of Children (Unduplicated) With at Least One Service 1379
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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 1360 4930.750000 109799.3700 108089.3700
D 3 5.500000 203.5000 0.0000
S 1 0.500000 18.5000 0.0000
H 22 71.000000 950.0000 900.0000
T 0 0.000000 0.0000 0.0000
3415 3179.250000 123738.7500 0.0000
Other 6 14.500000 747.2400 568.6400
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Total 4807 8201.500000 235457.3600 109558.0100