CMS/EIP Fiscal Report Center: 02
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 772 838.750000 31033.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 225 327.500000 12117.5000 37.0000
Subtotal (Total Children Is Unduplicated) 810 1166.250000 43151.2500 37.0000
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 23 28.000000 1400.0000 50.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 16 30.500000 2287.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 13 24.500000 1837.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 23 45.000000 2497.5000 55.5000
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 9 9.000000 450.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 62 147.000000 9037.2500 61.4779
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 807.4900 403.7450
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 27 34.750000 1737.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 31 36.500000 1825.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 8 7.500000 187.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 29 39.250000 1962.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 80 74.250000 3712.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 3 2.500000 62.5000 25.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 21 14.500000 725.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 5 4.000000 100.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 66 59.250000 2962.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 51 201.000000 10050.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 99 565.750000 28287.5000 50.0000
INTR-T1013-INTERPRETER 11 25.000000 1250.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 178 764.000000 7640.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 21.500000 1535.9600 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 6 28.000000 2000.3200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 13 29.000000 1906.8400 65.7531
PHY-97110GT-PT SESSION BY LICENSED PT 6 19.500000 1393.0800 71.4400
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 456.0000 456.0000
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 47.000000 3357.6800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 7 52.500000 3750.6000 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 46 54.000000 1998.0000 37.0000
TRAV-TRAVS-Travel by mile 40 3122.000000 1388.9800 0.4449
Subtotal (Total Children Is Unduplicated) 355 5209.750000 79438.4500 15.2480
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Total 6523.000000 131626.9500 20.1789
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Number of Children (Unduplicated) With at Least One Service 950
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Center 02
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 0 0.000000 0.0000 0.0000
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 1181 2125.250000 43692.6900 43692.6900
928 2901.000000 26907.7600 0.0000
Other 3224 1496.750000 61026.5000 0.0000
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Total 5333 6523.000000 131626.9500 43692.6900