CMS/EIP Fiscal Report Center: 02
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 823 714.000000 26418.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 238 289.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 855 1099.500000 40653.7500 36.9748
Subtotal (Total Children Is Unduplicated) 978 2102.750000 67071.7500 31.8972
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 32 38.750000 1937.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 9.000000 499.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 58 113.000000 8400.0000 74.3363
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 30 55.500000 4162.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 86 161.500000 8963.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 27.500000 2062.5000 75.0000
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 90.1000 45.0500
SCREEN-T1023-SCREENING 4 4.000000 200.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 153 423.250000 27095.6000 64.0180
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 6.000000 1482.0800 247.0133
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 40 51.500000 2575.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 3 3.250000 162.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 6 7.250000 181.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 124 101.000000 5037.5000 49.8762
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 14 13.250000 625.0000 47.1698
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 30 23.500000 1175.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 12 6.500000 325.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 101 76.000000 3800.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 12 7.000000 350.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 181 904.250000 45212.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 51 63.750000 3187.5000 50.0000
INTR-T1013-INTERPRETER 23 69.250000 3462.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 471 2536.000000 25360.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 26 110.000000 7848.4000 71.3491
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 26 115.000000 8047.8700 69.9815
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 40 192.500000 13752.2000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 7.250000 517.9400 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 16 10.000000 370.0000 37.0000
TRAV-TRAVS-Travel by mile 332 28515.00000 12686.6000 0.4449
Subtotal (Total Children Is Unduplicated) 677 32821.25000 136305.2800 4.1530
-----------------------------------------------------------------------------------------------------------------------
Total 35347.250000 230472.6300 6.5202
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1180
-----------------------------------------------------------------------------------------------------------------------
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 3 3.000000 100.0000 100.0000
H 0 0.000000 0.0000 0.0000
T 4608 19626.500000 112832.6100 112819.1700
100 265.500000 3111.5500 0.0000
Other 5616 15452.250000 114428.4700 0.0000
---------------------------------------------------------
Total 10327 35347.250000 230472.6300 112919.1700