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
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 607 299.500000 11081.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 916 3311.500000 122525.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1314 3611.000000 133607.0000 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
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 12.500000 937.5000 75.0000
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 3 4.500000 337.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 33 58.000000 3219.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.500000 487.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 63.500000 4762.5000 75.0000
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 165 376.250000 21455.9000 57.0256
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 502.4600 502.4600
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 37 131.000000 6550.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 76 445.750000 22287.5000 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-97530GT-OT SESSION BY LICENSED OT 2 13.000000 928.7200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 8 32.000000 1867.2200 58.3506
PHY-97110GT-PT SESSION BY LICENSED PT 8 40.000000 2571.1800 64.2795
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 16.000000 1143.0400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 11 67.750000 4770.0600 70.4068
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) 1049 23085.50000 153745.8800 6.6598
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Total 27072.750000 308808.7800 11.4066
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Number of Children (Unduplicated) With at Least One Service 1807
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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 0 0.000000 0.0000 0.0000
P 2818 8552.500000 69707.6600 69707.6600
D 395 1537.000000 5876.6100 0.0000
S 17 8.000000 296.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3173 12491.250000 57584.7500 57609.7500
7331 4484.000000 175343.7600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 13734 27072.750000 308808.7800 127317.4100