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
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 304 130.250000 4819.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 770 2371.750000 87662.2500 36.9610
Subtotal (Total Children Is Unduplicated) 969 2502.000000 92481.5000 36.9630
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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 2 3.500000 262.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 250.6600 71.6171
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.500000 112.5000 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 6 12.000000 666.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 43 73.000000 5304.5400 72.6649
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 20 31.000000 2325.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 19.500000 1082.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 70 124.000000 6882.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 11.500000 862.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 55 93.000000 6975.0000 75.0000
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
Subtotal (Total Children Is Unduplicated) 304 742.250000 43616.9500 58.7632
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EI Services,Class #03
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 32 46.000000 2300.0000 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 50 253.250000 12662.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 28 100.000000 5000.0000 50.0000
INTR-T1013-INTERPRETER 101 440.500000 22025.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 845 5912.000000 58548.0100 9.9032
OCCT-97530-OT SESSION BY LICENSED OT 4 18.000000 970.9200 53.9400
OCCT-97530GT-OT SESSION BY LICENSED OT 1 2.750000 196.4600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 6 27.000000 1737.5600 64.3541
PHY-97110GT-PT SESSION BY LICENSED PT 4 27.000000 1928.8800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 11 31.000000 2214.6400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 10 34.000000 2253.0100 66.2650
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) 1108 45011.50000 162977.0200 3.6208
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Total 48255.750000 299075.4700 6.1977
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Number of Children (Unduplicated) With at Least One Service 1615
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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 6746 31138.250000 112344.7200 112344.7200
D 607 3650.250000 10240.4500 0.0000
S 24 7.250000 268.2500 0.0000
H 1 0.250000 9.2500 0.0000
T 2928 10286.250000 48005.4900 48005.4900
5084 3145.750000 127180.5600 0.0000
Other 80 27.750000 1026.7500 0.0000
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Total 15470 48255.750000 299075.4700 160350.2100