CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/21/2020 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 607 299.750000 11090.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2412 9762.250000 361203.2500 37.0000
Subtotal (Total Children Is Unduplicated) 2436 10062.00000 372294.0000 37.0000
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 8 8.000000 388.0000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 109 212.750000 10637.5000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 8.000000 600.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 7 15.500000 1162.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 10.000000 555.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 40 66.500000 4930.4000 74.1414
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 11 20.500000 1537.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 12 19.500000 1462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 11.500000 638.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 194 316.000000 17538.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 21.000000 1575.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 249 526.000000 39450.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
SPCH-92610GT-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 445 1257.750000 81700.6000 64.9577
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 575.2200 287.6100
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 54 60.250000 3012.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 97 131.000000 6550.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 227 240.750000 6018.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 37 57.500000 2875.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 104 198.500000 9925.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 24 41.750000 1043.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 3 6.000000 300.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 55 105.750000 5287.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 7 7.000000 175.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 7 7.500000 375.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 52 86.250000 4312.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 2.000000 50.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 14 15.750000 787.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 95 170.250000 8512.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 28 34.750000 868.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 154 670.500000 33525.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 364 2170.500000 108525.0000 50.0000
INTR-T1013-INTERPRETER 49 255.250000 12762.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 614 3168.000000 31680.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 92.500000 6608.2000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 57 373.000000 26647.1200 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.750000 125.0200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 16 59.000000 3796.1000 64.3407
PHY-97110GT-PT SESSION BY LICENSED PT 52 417.750000 29254.8700 70.0296
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 102.250000 7304.7400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 116 720.750000 51350.3800 71.2458
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 132 295.750000 10942.7500 37.0000
TRAV-TRAVS-Travel by mile 315 17455.00000 7646.7000 0.4381
Subtotal (Total Children Is Unduplicated) 1193 26949.00000 380837.3500 14.1318
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Total 38268.750000 834831.9500 21.8150
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Number of Children (Unduplicated) With at Least One Service 2465
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Center 01
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 0.750000 27.7500 0.0000
P 4286 9979.000000 150106.6000 150106.6000
D 531 1671.750000 13039.2200 0.0000
S 4400 2928.000000 119991.7900 0.0000
H 7592 5379.750000 238056.2800 200601.3100
T 4070 13378.500000 109609.2200 109164.6000
7636 4804.000000 195001.5900 0.0000
Other 77 127.000000 8999.5000 0.0000
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Total 28593 38268.750000 834831.9500 459872.5100