CMS/EIP Fiscal Report Center: 03
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/20/2020 Page: 1
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 680 398.500000 14744.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 6.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1103 3284.250000 121517.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1139 3688.750000 136261.7500 36.9398
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 3 6.000000 300.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 13.500000 1012.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 8.500000 471.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 87 155.000000 11625.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 41 72.500000 5437.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 11 18.500000 1387.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 41 71.500000 3968.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 40.000000 3000.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 52.3700 26.1850
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW 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 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 3 3.000000 150.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 2 2.000000 102.1000 51.0500
SPCH-92610GT-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 133 419.000000 29161.5700 69.5980
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 43 43.000000 2150.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 175 245.750000 12287.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 10 11.750000 293.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 32 42.000000 2100.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 181 308.000000 15400.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 18 21.750000 1087.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 39 51.750000 2587.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 18 33.500000 1675.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 11 18.750000 937.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 27 33.000000 1650.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 64 101.750000 5087.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.500000 37.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 2.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 89 320.500000 16025.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 152 674.750000 33737.5000 50.0000
INTR-T1013-INTERPRETER 2 22.750000 1112.5000 48.9011
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 61 205.000000 2050.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 19.750000 1210.1500 61.2734
OCCT-97530GT-OT SESSION BY LICENSED OT 8 34.750000 2482.5400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 2 4.000000 285.7600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 11 32.500000 2321.8000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 17 36.500000 2545.7400 69.7463
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 22.000000 1335.8200 60.7191
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 27 88.750000 6340.3000 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 6 7.750000 553.6600 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 16 18.750000 693.7500 37.0000
TRAV-TRAVS-Travel by mile 207 14268.00000 6347.6100 0.4449
Subtotal (Total Children Is Unduplicated) 542 16673.25000 122503.7600 7.3473
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Total 20781.000000 287927.0800 13.8553
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Number of Children (Unduplicated) With at Least One Service 1239
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Center 03
Flag Claims Units Chgs Paid
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R 172 137.750000 5481.2100 0.0000
U 0 0.000000 0.0000 0.0000
B 3147 2079.750000 80624.2500 0.0000
P 366 1745.000000 13425.7800 13425.7800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 83 937.500000 3019.8000 3019.8000
T 0 0.000000 0.0000 0.0000
6212 15881.000000 185376.0400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 9980 20781.000000 287927.0800 16445.5800