CMS/EIP Fiscal Report Center: 03
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 696 405.750000 15012.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7 7.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 414 1250.500000 46268.5000 37.0000
Subtotal (Total Children Is Unduplicated) 852 1663.250000 61281.2500 36.8443
-----------------------------------------------------------------------------------------------------------------------
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 6 10.500000 787.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 3.500000 262.5000 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 3 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 42 81.500000 6112.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 21 35.500000 2662.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 8.500000 637.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 24 44.500000 2469.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 30.000000 2250.0000 75.0000
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-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 1 1.000000 50.0000 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 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) 83 245.500000 17088.3500 69.6063
-----------------------------------------------------------------------------------------------------------------------
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 182 310.750000 15537.5000 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 65 103.750000 5187.5000 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 137 623.000000 31150.0000 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 6 13.000000 928.7200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 5 31.000000 2214.6400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 10 30.500000 2178.9200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 8 22.500000 1545.5800 68.6924
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 17.500000 1164.3400 66.5337
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 10 54.250000 3875.6200 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) 525 16547.00000 114842.9300 6.9404
-----------------------------------------------------------------------------------------------------------------------
Total 18455.750000 193212.5300 10.4690
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1072
-----------------------------------------------------------------------------------------------------------------------
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 365 1744.000000 13458.7400 13458.7400
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
6130 15774.250000 176733.9900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6578 18455.750000 193212.5300 16478.5400