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
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 1089 1680.500000 62169.2500 36.9945
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 12 6.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 342 1182.500000 43743.2500 36.9922
Subtotal (Total Children Is Unduplicated) 1131 2869.250000 105912.5000 36.9130
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 4 9.000000 450.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 2 4.000000 200.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 49 74.000000 3700.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 13 24.006933 1800.5200 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 6.955335 521.6500 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 5.333333 400.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 24 48.000000 2664.0000 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 2 1.140059 58.2000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 2.824681 144.2000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 101 184.593674 10590.6700 57.3729
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EI Services,Class #03
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 10 16.000000 800.0000 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 52 267.500000 13375.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 58 321.500000 16075.0000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 120.0000 60.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 425 2654.000000 26540.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 32.611561 2329.7700 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 4 10.935890 781.2600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 5 11.242832 643.0900 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 6 22.409790 1281.8400 57.2000
PHY-97110-PT SESSION BY LICENSED PT 3 7.000000 500.0800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 4 9.236282 659.8400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 4 16.000000 914.5600 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 4 8.572078 489.9800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 25 117.854140 8419.5000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 17 51.161954 3655.0100 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) 556 6759.274527 91020.3400 13.4660
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Total 9813.118201 207523.5100 21.1476
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Number of Children (Unduplicated) With at Least One Service 1188
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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 0 0.000000 0.0000 0.0000
P 3040 4863.273121 65363.9800 65381.2000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 3.250000 209.2500 0.0000
T 0 0.000000 0.0000 0.0000
6334 4946.595080 141950.2800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 9377 9813.118201 207523.5100 65381.2000