CMS/EIP Fiscal Report Center: 57
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 842 459.250000 16992.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 64 97.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1693 8056.500000 298090.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1747 8613.500000 315082.7500 36.5801
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 3 3.000000 150.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 15 20.500000 1537.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 10 12.000000 900.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 7.000000 525.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 3.500000 262.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 21 28.000000 1554.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 14 16.500000 915.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 48 64.000000 4800.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 66 85.500000 6412.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 15.500000 1162.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 18 25.000000 1875.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 24 34.500000 2587.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 44 58.500000 4387.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 75 104.500000 5799.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 118 161.000000 8935.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 11.500000 862.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 9.000000 675.0000 75.0000
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 259 677.500000 44405.1000 65.5426
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 14 14.000000 700.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 88 86.000000 4300.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 3 3.000000 75.0000 25.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 4 4.000000 200.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 144 139.000000 6950.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 4 3.500000 87.5000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 8 68.000000 1700.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 39 116.000000 5800.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 792 4590.750000 229537.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 35 97.000000 970.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 10 39.000000 2786.1600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.500000 85.8000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 12 37.500000 2679.0000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 1.500000 85.7400 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 6 6.250000 357.2500 57.1600
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 0.500000 35.7200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.500000 107.1600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 14 57.000000 4072.0800 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 15 27.000000 1544.4000 57.2000
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 1 2.000000 114.4000 57.2000
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 117 231.500000 8565.5000 37.0000
Subtotal (Total Children Is Unduplicated) 875 5531.500000 271074.7300 49.0056
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Total 14822.500000 630562.5800 42.5409
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Number of Children (Unduplicated) With at Least One Service 1756
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Center 57
Flag Claims Units Chgs Paid
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R 1 0.250000 9.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 687 798.250000 31330.7500 157.2500
P 4342 4376.000000 171226.2500 168574.5500
D 2 1.750000 64.7500 64.7500
S 5 5.500000 242.5000 242.5000
H 2 2.000000 150.0000 0.0000
T 1119 2364.750000 112149.3800 112149.3800
5878 7260.500000 314734.2000 158339.9500
Other 10 13.500000 655.5000 655.5000
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Total 12046 14822.500000 630562.5800 440183.8800