CMS/EIP Fiscal Report Center: 05
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 396 156.250000 5781.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 3.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1119 3332.250000 123293.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1124 3491.500000 129074.5000 36.9682
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 7.000000 525.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.500000 262.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 5 7.000000 525.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 13.500000 1012.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 24 41.000000 2275.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 21 34.500000 1914.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 30 55.500000 4162.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 42 67.000000 5025.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 20.500000 1137.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 20 37.500000 2081.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.500000 562.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 357.3500 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) 163 326.000000 21478.4500 65.8848
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 36 27.750000 1387.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 65 65.000000 3250.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 0.500000 12.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 32 20.750000 1037.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 44 28.000000 1400.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 8 4.000000 100.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 6 3.750000 187.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 16 10.750000 537.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 7 3.250000 81.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 2.500000 125.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 8 5.500000 275.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 6 3.500000 87.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 18 15.750000 787.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 27 15.500000 775.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 4 2.500000 62.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 130 494.000000 24700.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 137 528.750000 26437.5000 50.0000
INTR-T1013-INTERPRETER 2 4.000000 200.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 413 1729.000000 17290.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 39.250000 2570.7500 65.4968
OCCT-97530GT-OT SESSION BY LICENSED OT 24 101.750000 6241.8900 61.3454
PHY-97110-PT SESSION BY LICENSED PT 15 56.500000 3314.2300 58.6589
PHY-97110GT-PT SESSION BY LICENSED PT 25 91.500000 5244.0500 57.3120
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 31 66.000000 4107.5900 62.2362
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 54 203.750000 12068.0300 59.2296
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 27 49.750000 1840.7500 37.0000
TRAV-TRAVS-Travel by mile 416 30724.00000 13668.8200 0.4449
Subtotal (Total Children Is Unduplicated) 558 34297.25000 127789.8600 3.7260
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Total 38114.750000 278342.8100 7.3028
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Number of Children (Unduplicated) With at Least One Service 1146
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Center 05
Flag Claims Units Chgs Paid
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R 28 33.500000 2121.8200 0.0000
U 0 0.000000 0.0000 0.0000
B 3137 2012.250000 75627.4000 44146.0000
P 3407 32386.250000 136392.9600 136392.9600
D 36 25.250000 1048.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2827 3657.500000 63152.3800 8568.1300
Other 0 0.000000 0.0000 0.0000
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Total 9435 38114.750000 278342.8100 189107.0900