CMS/EIP Fiscal Report Center: 52
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 325 147.000000 5439.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 200 134.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 777 2352.250000 86767.0000 36.8868
Subtotal (Total Children Is Unduplicated) 840 2634.000000 92206.0000 35.0061
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 3 3.000000 150.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 36.000000 2700.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 28.000000 2100.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 17 34.000000 1887.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 176 364.000000 26594.8400 73.0627
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 104 218.000000 15822.4000 72.5798
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 46 98.000000 6928.1500 70.6954
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 180 362.500000 19869.0000 54.8110
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 37.500000 2812.5000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 7 7.000000 357.3500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
SCREEN-T1023-SCREENING 55 56.000000 2750.0000 49.1071
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 26 26.000000 1327.3000 51.0500
Subtotal (Total Children Is Unduplicated) 290 1296.000000 84961.1400 65.5564
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 129 146.250000 7287.5000 49.8291
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 11 9.250000 231.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 128 222.000000 11100.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 2 3.250000 162.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 11 9.500000 237.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 111 184.750000 9237.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 5 4.750000 237.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 26 23.500000 1175.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 3 1.500000 37.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 77 114.000000 5700.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 5 1.750000 43.7500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 33 52.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 386 2039.000000 101815.0000 49.9338
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 51 52.000000 2600.0000 50.0000
INTR-T1013-INTERPRETER 11 83.500000 4175.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 674 4969.000000 49690.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 100 443.000000 31062.1600 70.1177
OCCT-97530GT-OT SESSION BY LICENSED OT 6 5.750000 410.7800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 38 215.500000 12326.6000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 7 7.750000 443.3000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 70 432.750000 29397.5600 67.9320
PHY-97110GT-PT SESSION BY LICENSED PT 8 8.250000 517.9400 62.7806
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 226 1267.000000 89345.1700 70.5171
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 26 26.750000 1911.0200 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 13 9.500000 351.5000 37.0000
TRAV-TRAVS-Travel by mile 554 45678.00000 20322.9700 0.4449
Subtotal (Total Children Is Unduplicated) 740 56014.50000 379930.0000 6.7827
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Total 59944.500000 557097.1400 9.2935
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Number of Children (Unduplicated) With at Least One Service 923
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Center 52
Flag Claims Units Chgs Paid
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R 5 3.250000 120.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 326 305.750000 15224.9100 150.0000
P 1420 1465.000000 68796.9200 67626.8600
D 4 4.000000 200.0000 200.0000
S 544 522.000000 19966.0000 355.7500
H 157 212.000000 14320.6600 447.7600
T 6603 53030.000000 228734.4500 217290.4600
3359 4402.500000 209733.9500 439.0400
Other 0 0.000000 0.0000 0.0000
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Total 12418 59944.500000 557097.1400 286509.8700