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
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 304 130.250000 4819.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2326 7039.250000 260359.7500 36.9869
Subtotal (Total Children Is Unduplicated) 2333 7169.500000 265179.0000 36.9871
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 4 4.000000 194.0000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 173 343.250000 17162.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 19.500000 1462.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 11 18.000000 1338.1600 74.3422
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 7.000000 525.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 21 46.500000 3487.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 9 23.000000 1725.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 17 34.500000 1914.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 21.000000 1575.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 182 303.000000 22554.5400 74.4374
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 20.000000 1500.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 64 101.000000 7575.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 11.500000 862.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 39 65.500000 3635.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 255 428.500000 23781.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 43.500000 3262.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 232 415.500000 31162.5000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 3.000000 150.0000 50.0000
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 3.000000 150.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 657 1928.750000 125047.1500 64.8333
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 1205.9200 1205.9200
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 97 113.750000 5687.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 101 128.250000 6412.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 56 52.000000 1300.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 52 82.500000 4125.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 75 119.250000 5962.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 14 13.250000 331.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 39 56.750000 2837.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 10 16.500000 825.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 4 4.750000 118.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 33 47.000000 2350.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 8 8.000000 400.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 2.000000 50.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 57 74.750000 3737.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 31 51.500000 2575.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 10 11.500000 287.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 267 1594.250000 79712.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 196 732.750000 36637.5000 50.0000
INTR-T1013-INTERPRETER 103 444.000000 22200.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 845 5912.000000 58548.0100 9.9032
OCCT-97530-OT SESSION BY LICENSED OT 38 123.000000 7797.1200 63.3912
OCCT-97530GT-OT SESSION BY LICENSED OT 35 105.500000 7536.9200 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 1 0.750000 53.5800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 50 176.000000 12096.1500 68.7281
PHY-97110GT-PT SESSION BY LICENSED PT 34 123.250000 8804.9800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 62 281.500000 19645.0600 69.7871
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 74 293.500000 20791.6900 70.8405
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 142.8800 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 49 66.250000 2451.2200 36.9995
TRAV-TRAVS-Travel by mile 451 37319.00000 16038.8200 0.4298
Subtotal (Total Children Is Unduplicated) 1213 47956.50000 330662.3500 6.8950
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Total 57054.750000 720888.5000 12.6350
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Number of Children (Unduplicated) With at Least One Service 2347
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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 8 2.000000 74.0000 0.0000
P 8101 32486.250000 186610.5100 186610.5100
D 792 3835.000000 20014.7000 0.0000
S 3712 2426.500000 109668.6700 0.0000
H 6001 3753.000000 163375.6800 125725.2500
T 3536 10894.000000 82008.9100 80733.3300
5243 3309.250000 137801.5300 0.0000
Other 367 348.750000 21334.5000 0.0000
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Total 27760 57054.750000 720888.5000 393069.0900