CMS/EIP Fiscal Report Center: 02
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 624 753.500000 27879.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 19 12.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 538 812.000000 30044.0000 37.0000
Subtotal (Total Children Is Unduplicated) 690 1578.250000 57923.5000 36.7011
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 14 21.250000 1062.5000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 333.0000 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 48 86.000000 6450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 23.500000 1762.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 28 55.500000 4162.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 33.500000 1859.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 80 154.000000 8547.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 8 8.000000 400.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 286.3000 47.7167
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 140 420.750000 26600.8500 63.2225
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 498.9800 249.4900
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 27 33.500000 1675.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 31 39.250000 1962.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 2.750000 68.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 35 28.000000 1400.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 33 35.000000 1750.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 3 1.500000 37.5000 25.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 12 11.750000 587.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 13 8.500000 425.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 40 34.250000 1712.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 60 365.000000 18250.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 75 335.750000 16787.5000 50.0000
INTR-T1013-INTERPRETER 15 83.250000 4162.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 239 1412.000000 14120.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 45.000000 3214.8000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 8 38.000000 2714.7200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 17 83.750000 5603.5500 66.9081
PHY-97110GT-PT SESSION BY LICENSED PT 2 6.000000 272.7800 45.4633
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 157.500000 11044.0400 70.1209
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 16 81.000000 5786.6400 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 9 10.250000 379.2500 37.0000
TRAV-TRAVS-Travel by mile 65 5491.000000 2442.9000 0.4449
Subtotal (Total Children Is Unduplicated) 380 8306.000000 94921.4100 11.4281
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Total 10305.000000 179445.7600 17.4135
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Number of Children (Unduplicated) With at Least One Service 825
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Center 02
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 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2633 7814.750000 77704.2200 77433.4400
345 313.250000 8924.9000 0.0000
Other 3701 2177.000000 92816.6400 0.0000
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Total 6679 10305.000000 179445.7600 77433.4400