CMS/EIP Fiscal Report Center: 05
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 492 207.750000 7686.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 422 396.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1192 3413.250000 126290.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1195 4017.250000 133977.0000 33.3504
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 22.500000 1687.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 12.000000 900.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 44 65.500000 3635.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 71 116.500000 8737.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 42 66.500000 4987.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 67 111.500000 6188.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 20.000000 1500.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 64.6800 32.3400
OCTH-97167-OT EVAL HIGH COMPLEXITY 12 12.000000 586.2400 48.8533
PSTH-97163-PT EVAL HIGH COMPLEXITY 8 9.000000 459.4500 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 19 21.000000 944.4100 44.9719
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 89.1000 44.5500
Subtotal (Total Children Is Unduplicated) 234 477.000000 30876.4300 64.7305
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 121 111.500000 5575.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 4 4.000000 200.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 1.500000 37.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 107 69.750000 3487.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 3 1.250000 62.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 4 1.750000 43.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 33 21.000000 1050.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.500000 12.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 26 14.500000 725.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 2 1.000000 50.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 3 1.750000 43.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 71 49.000000 2450.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 4 1.000000 25.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 12 49.000000 1225.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 305 1753.500000 87675.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 31 35.750000 1787.5000 50.0000
INTR-T1013-INTERPRETER 13 71.000000 3550.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 743 5237.000000 52370.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 36 191.000000 12833.5300 67.1913
OCCT-97530GT-OT SESSION BY LICENSED OT 7 13.000000 867.0600 66.6969
PHY-97110-PT SESSION BY LICENSED PT 50 261.500000 16144.0600 61.7364
PHY-97110GT-PT SESSION BY LICENSED PT 10 15.000000 1031.6000 68.7733
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 14.3700 14.3700
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 129 610.750000 38650.9100 63.2843
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 14 16.250000 1062.6800 65.3957
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 16 8.250000 305.2500 37.0000
TRAV-TRAVS-Travel by mile 775 90715.00000 40307.5900 0.4443
Subtotal (Total Children Is Unduplicated) 813 99256.50000 271587.0500 2.7362
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Total 103750.750000 436440.4800 4.2066
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Number of Children (Unduplicated) With at Least One Service 1257
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Center 05
Flag Claims Units Chgs Paid
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R 21 14.750000 685.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3197 2112.000000 81565.4500 55809.8700
P 8751 99409.750000 290785.9500 290785.9500
D 40 23.250000 898.2500 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
3475 2191.000000 62505.0800 4026.5800
Other 0 0.000000 0.0000 0.0000
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Total 15484 103750.750000 436440.4800 350622.4000