CMS/EIP Fiscal Report Center: 54
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 930 809.500000 29914.5000 36.9543
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 130 96.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1492 5582.000000 206120.7500 36.9260
Subtotal (Total Children Is Unduplicated) 1519 6487.500000 236035.2500 36.3831
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 12 12.000000 582.0000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 3 4.000000 200.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 10 16.500000 1237.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 8 12.500000 937.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 10 17.000000 1250.0000 73.5294
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 12 22.000000 1221.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 28.000000 2100.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 83 144.000000 10762.5000 74.7396
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 82 133.500000 10012.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 50 84.000000 6300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 3.500000 194.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 163 283.500000 15734.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 15.500000 1162.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 98 181.500000 13612.5000 75.0000
SCREEN-T1023-SCREENING 13 13.000000 650.0000 50.0000
Subtotal (Total Children Is Unduplicated) 284 984.500000 66977.2500 68.0317
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 13 20.000000 3373.2500 168.6625
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 56 51.250000 2562.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 88 100.000000 5000.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 4.750000 118.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 147 78.750000 3937.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 508 584.000000 29187.5000 49.9786
CONIP-CONIP-CONSULT, ITDS PHONE 2 1.750000 43.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 70 29.000000 1450.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 385 182.250000 9112.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.500000 12.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 82 43.750000 2187.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 191 99.000000 4950.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 44 19.500000 481.2500 24.6795
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 58 36.250000 1812.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 277 186.750000 9337.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.500000 37.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 9 8.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 100 216.750000 10837.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 535 3319.500000 165975.6600 50.0002
INTR-T1013-INTERPRETER 18 69.750000 1743.7500 25.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 53 65.000000 650.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 2.500000 178.6000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 65 269.000000 19253.0800 71.5728
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 53 238.500000 17038.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 11 23.500000 1678.8400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 53 236.250000 16877.7000 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 2 2.000000 142.8800 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 39 148.500000 10608.8400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 0.250000 17.8600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 72 314.000000 22432.1600 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 5 5.000000 357.2000 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 46 173.250000 12376.9800 71.4400
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 5 7.000000 97.1600 13.8800
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 156 255.250000 9444.2500 37.0000
TRAV-TRAVS-Travel by mile 34 579.000000 257.5900 0.4449
Subtotal (Total Children Is Unduplicated) 906 7373.500000 363644.4300 49.3178
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Total 14845.500000 666656.9300 44.9063
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Number of Children (Unduplicated) With at Least One Service 1535
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Center 54
Flag Claims Units Chgs Paid
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R 7 4.500000 261.2100 0.0000
U 0 0.000000 0.0000 0.0000
B 2461 2054.750000 92940.9600 9.2500
P 1611 1323.500000 57440.9100 57303.8400
D 89 67.000000 3477.7600 9.2500
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1513 1437.920000 42151.1700 42123.4200
13579 9929.830000 468419.0400 0.0000
Other 29 28.000000 1965.8800 0.0000
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Total 19289 14845.500000 666656.9300 99445.7600