CMS/EIP Fiscal Report Center: 55
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 1248 1303.750000 48238.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 299 228.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 401 1362.000000 50394.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1305 2894.250000 98632.7500 34.0789
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 22 37.000000 1850.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 49 79.000000 3950.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 32 51.941332 3895.5999 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 0.836800 62.7600 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 48.752266 3656.4200 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 29.528534 2214.6400 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 32.000000 1776.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.621200 196.5900 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 0.118511 6.0500 51.0501
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 2.510284 128.1500 51.0500
Subtotal (Total Children Is Unduplicated) 140 288.308927 17940.4099 62.2263
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 523.6000 523.6000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 9 8.750000 437.5000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 107 114.250000 5712.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 95 115.250000 2881.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 56 98.000000 4900.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 64 156.500000 3912.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 1.500000 37.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 82 86.500000 4325.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 56 44.500000 1112.5000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 25.500000 637.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 123 768.250000 38412.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 14 14.750000 737.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 822 7095.000000 70950.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 18 112.785132 8057.3700 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 22 90.737417 5190.1800 57.2000
PHY-97110-PT SESSION BY LICENSED PT 9 21.671752 1548.2300 71.4400
PHY-97110HM-PT SESSION BY PT ASST 7 29.038665 1659.8500 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 44 190.055441 13577.5600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.750000 196.4600 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 17 8.500000 314.5000 37.0000
TRAV-TRAVS-Travel by mile 122 5627.000000 2503.2700 0.4449
Subtotal (Total Children Is Unduplicated) 875 14613.28841 167677.2700 11.4743
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Total 17795.847334 284250.4299 15.9729
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Number of Children (Unduplicated) With at Least One Service 1379
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Center 55
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 7185 11281.061421 127441.8300 127441.8300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 459 639.000000 6936.7100 6936.7100
7487 5875.785913 149871.8899 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 15131 17795.847334 284250.4299 134378.5400