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
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 930 809.000000 29896.0000 36.9543
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 130 96.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 472 1706.750000 63038.7500 36.9350
Subtotal (Total Children Is Unduplicated) 1138 2611.750000 92934.7500 35.5833
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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 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.500000 637.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 10 17.500000 1312.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 16 24.000000 1800.0000 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 5 9.000000 675.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 37 62.000000 3441.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 30.500000 2287.5000 75.0000
SCREEN-T1023-SCREENING 3 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 71 195.000000 12864.5000 65.9718
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 12 18.000000 2346.4900 130.3606
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 7 14.000000 700.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 83 548.500000 27425.0000 50.0000
INTR-T1013-INTERPRETER 18 69.750000 1743.7500 25.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 53 65.000000 650.0000 10.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 19 76.250000 5447.3000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 3 3.750000 267.9000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 18 119.500000 8537.0800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 17 49.250000 3518.4200 71.4400
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) 748 3225.750000 130569.0300 40.4771
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Total 6032.500000 236368.2800 39.1825
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Number of Children (Unduplicated) With at Least One Service 1220
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Center 54
Flag Claims Units Chgs Paid
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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 3 0.750000 27.7500 27.7500
D 1 0.250000 9.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1372 1297.750000 33750.7800 33723.0300
8252 4733.750000 202580.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 9628 6032.500000 236368.2800 33750.7800