CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 289 124.750000 4615.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 725 2188.250000 80872.7500 36.9577
Subtotal (Total Children Is Unduplicated) 916 2313.000000 85488.5000 36.9600
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 17 26.500000 1987.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 10 16.500000 1237.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 40 71.500000 3968.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 48.500000 3637.5000 75.0000
Subtotal (Total Children Is Unduplicated) 85 200.000000 13401.0000 67.0050
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 41 49.250000 2462.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 9 11.750000 587.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 21 19.250000 481.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 16 20.500000 1025.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 4 5.000000 250.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 4 5.000000 125.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 25 29.750000 1487.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 2.000000 50.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 20 24.000000 1200.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 2 2.000000 100.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 42 53.750000 2687.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 2 2.000000 100.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 7 8.000000 200.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 3.000000 150.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 7 28.000000 1400.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 3.000000 214.3200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 1 2.750000 196.4600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 3 9.000000 642.9600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 23.000000 1643.1200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 17.000000 1214.4800 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 19 27.500000 1017.5000 37.0000
Subtotal (Total Children Is Unduplicated) 165 348.500000 17402.9700 49.9368
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Total 2861.500000 116292.4700 40.6404
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Number of Children (Unduplicated) With at Least One Service 996
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Center 01
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 0 0.000000 0.0000 0.0000
D 3 4.500000 166.5000 0.0000
S 22 6.250000 231.2500 0.0000
H 1 0.250000 9.2500 0.0000
T 0 0.000000 0.0000 0.0000
4768 2823.500000 114886.4700 0.0000
Other 77 27.000000 999.0000 0.0000
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Total 4871 2861.500000 116292.4700 0.0000