CMS/EIP Fiscal Report Center: 55
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 1089 1680.500000 62169.2500 36.9945
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 12 6.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1190 4167.750000 154151.2500 36.9867
Subtotal (Total Children Is Unduplicated) 1232 5854.500000 216320.5000 36.9494
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 6 12.000000 600.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 2 4.000000 200.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 59 86.000000 4300.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 10 20.000000 1500.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 6 12.000000 900.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 10.829867 812.2400 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 224 454.836800 34112.7600 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 29 58.000001 4350.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 91 186.333333 13975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 95 190.000000 10545.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.333333 100.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 4 4.000000 204.2000 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 10 10.000000 510.5000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 22 22.000000 1123.1000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 357.3500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 97.8800 48.9400
Subtotal (Total Children Is Unduplicated) 367 1116.333334 75731.8300 67.8398
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 523.8000 523.8000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 2.250000 112.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 1 0.500000 25.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 54 54.250000 2712.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 1 1.000000 50.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 77 81.500000 2037.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 19 33.000000 1650.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 12 20.000000 1000.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 43 73.500000 1837.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 48 49.500000 2475.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 2 2.000000 100.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 57 51.000000 1275.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 1.500000 37.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 193 1015.250000 50762.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 179 821.750000 41087.5000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 120.0000 60.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 425 2657.000000 26570.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 59 306.000000 21860.6400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 26 136.250000 9733.7000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 60 196.250000 11225.5000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 45 208.750000 11940.5000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 28 116.500000 8322.7600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 15 47.986282 3428.1400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 30 191.250000 10931.8500 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 11 46.750001 2672.2300 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 168 983.613098 70269.3197 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 70 296.370661 21172.7200 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 12 75.250000 5375.8600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 6 29.750000 2125.3400 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 13 23.250000 860.2500 37.0000
TRAV-TRAVS-Travel by mile 51 2838.000000 1262.6600 0.4449
Subtotal (Total Children Is Unduplicated) 644 10362.97004 313557.7697 30.2575
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Total 17333.803376 605610.0997 34.9381
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Number of Children (Unduplicated) With at Least One Service 1246
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Center 55
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 2631 2254.583333 99733.0900 92.5000
P 5757 6701.273121 150551.5900 151420.9100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 53 83.250000 5847.1900 0.0000
T 0 0.000000 0.0000 0.0000
9739 8293.860122 349415.4697 0.0000
Other 1 0.836800 62.7600 0.0000
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Total 18181 17333.803376 605610.0997 151513.4100