CMS/EIP Fiscal Report Center: 04
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 883 1009.000000 37333.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1654 7608.750000 281508.7500 36.9980
Subtotal (Total Children Is Unduplicated) 1708 8617.750000 318841.7500 36.9983
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 42 64.000000 3200.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 11 11.000000 825.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 18 19.000000 1425.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 22 37.000000 2775.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 39 80.000000 4440.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 36 40.000000 3000.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 61 65.000000 4875.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 128 250.500000 13902.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 73 95.000000 7125.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97165TLGT-OT EVAL LOW COMPLEXITY 1 3.000000 153.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 9 9.000000 459.4500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 7 7.000000 321.0300 45.8614
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 6 6.000000 282.7400 47.1233
PSTH-97163-PT EVAL HIGH COMPLEXITY 8 9.000000 459.4500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 8 8.000000 408.4000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 220.1600 44.0320
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 260 717.500000 44331.5800 61.7862
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EI Services,Class #03
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 9 15.250000 381.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 470 3284.000000 164150.0000 49.9848
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 452 3521.250000 175987.5000 49.9787
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 513 3496.000000 34960.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 25 94.250000 6545.5000 69.4483
OCCT-97530GT-OT SESSION BY LICENSED OT 12 76.000000 5069.3600 66.7021
OCCT-97530HM-OT SESSION BY OT ASST 21 84.000000 4609.6000 54.8762
OCCT-97530HMGT-OT SESSION BY OT ASST 25 108.500000 6206.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 37 173.000000 12112.6400 70.0153
PHY-97110GT-PT SESSION BY LICENSED PT 10 44.000000 2982.7200 67.7891
PHY-97110HM-PT SESSION BY PT ASST 19 155.000000 8859.8000 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 6 11.000000 628.7600 57.1600
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 14.000000 1000.1600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 21 93.500000 6371.5300 68.1447
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 0.500000 35.7200 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 5 15.000000 555.0000 37.0000
Subtotal (Total Children Is Unduplicated) 921 11186.25000 430527.1800 38.4872
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Total 20521.500000 793700.5100 38.6765
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Number of Children (Unduplicated) With at Least One Service 1825
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Center 04
Flag Claims Units Chgs Paid
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R 450 592.500000 21922.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 3026 4382.250000 162128.2500 0.0000
P 1978 5838.000000 148719.4600 137991.8200
D 3 5.500000 203.5000 0.0000
S 2 2.500000 92.5000 0.0000
H 1735 5980.250000 302306.1400 900.0000
T 0 0.000000 0.0000 0.0000
3775 3599.000000 150255.2500 0.0000
Other 48 121.500000 8072.9100 1676.9700
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Total 11017 20521.500000 793700.5100 140568.7900