CMS/EIP Fiscal Report Center: 54
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 882 734.500000 27158.0000 36.9748
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 815 789.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 509 1579.000000 58358.2500 36.9590
Subtotal (Total Children Is Unduplicated) 1384 3103.000000 85516.2500 27.5592
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 14 17.000000 824.5000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 33 57.750000 2887.5000 50.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 112.5000 56.2500
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 21.000000 1575.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 8.000000 600.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 10.500000 787.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 30.000000 1665.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 34.500000 2587.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
SCREEN-T1023-SCREENING 3 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 102 198.750000 12217.0000 61.4692
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 20.000000 1623.6300 81.1815
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 107 120.000000 5975.0000 49.7917
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 2 1.500000 75.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 3.250000 81.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 503 579.250000 28962.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 83 31.000000 1550.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 37 9.750000 243.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 329 137.500000 6875.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 5 3.000000 150.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 19 6.500000 156.2500 24.0385
CONPF-CONPF-CONSULT, PT, FACE TO FACE 185 97.500000 4875.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 16 7.000000 350.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 29 7.500000 187.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 143 93.500000 4637.5000 49.5989
CONSP-CONSP-CONSULT, SLP, PHONE 14 4.750000 118.7500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 771 1877.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 105 611.000000 30550.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 18 25.500000 1275.0000 50.0000
INTR-T1013-INTERPRETER 20 74.000000 1850.0000 25.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1192 6825.000000 68250.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 18 109.750000 7840.5400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 6 11.000000 785.8400 71.4400
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 15 82.000000 5858.0800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 7 8.000000 571.5200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 23 85.750000 6125.9800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 4.000000 285.7600 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 73 55.750000 2062.7500 37.0000
TRAV-TRAVS-Travel by mile 878 70239.00000 31220.6200 0.4445
Subtotal (Total Children Is Unduplicated) 1214 81130.75000 212594.4200 2.6204
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Total 84432.500000 310327.6700 3.6755
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Number of Children (Unduplicated) With at Least One Service 1557
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Center 54
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 1 0.250000 9.2500 0.0000
P 2 1.250000 18.5000 74.0000
D 26 23.000000 1504.1900 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 8947 56232.000000 105498.4000 105092.4600
14687 28176.000000 203297.3300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 23663 84432.500000 310327.6700 105166.4600