CMS/EIP Fiscal Report Center: 03
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 758 425.250000 15734.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 376 343.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 459 1345.000000 49765.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1034 2114.000000 65499.2500 30.9836
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 71 87.250000 4362.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 10.000000 750.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 11.500000 638.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 84 153.500000 11512.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 36 66.500000 4987.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 67 121.000000 6715.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 26.500000 1987.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97166-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-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 45 46.000000 2300.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 239 544.750000 34627.3500 63.5656
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 722.0000 722.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 200 249.000000 12450.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 14 28.750000 1437.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 13 7.750000 193.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 264 497.250000 24862.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 35 38.250000 1912.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 13 10.750000 268.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 97 157.250000 7862.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 2 4.000000 200.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 48 77.750000 3887.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 105 149.000000 7450.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 4 4.000000 200.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 258 328.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 214 958.500000 47925.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 53 83.250000 4162.5000 50.0000
INTR-T1013-INTERPRETER 8 65.500000 3098.2400 47.3014
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 162 767.000000 7650.0000 9.9739
OCCT-97530-OT SESSION BY LICENSED OT 16 75.250000 5361.6200 71.2508
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 26 99.000000 6658.9600 67.2622
PHY-97110GT-PT SESSION BY LICENSED PT 4 5.000000 357.2000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 26 114.250000 7871.0100 68.8929
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 9.000000 642.9600 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
TRAV-TRAVS-Travel by mile 657 58563.00000 26034.1000 0.4445
Subtotal (Total Children Is Unduplicated) 765 62297.25000 171381.4100 2.7510
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Total 64956.000000 271508.0100 4.1799
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Number of Children (Unduplicated) With at Least One Service 1302
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Center 03
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 2424 23277.750000 53119.6900 53119.6900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 235 2106.000000 5701.0200 5701.0200
T 0 0.000000 0.0000 0.0000
9059 39572.250000 212687.3000 115.7000
Other 0 0.000000 0.0000 0.0000
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Total 11718 64956.000000 271508.0100 58936.4100