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
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 624 753.500000 27879.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 19 12.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 154 230.500000 8528.5000 37.0000
Subtotal (Total Children Is Unduplicated) 638 996.750000 36408.0000 36.5267
-----------------------------------------------------------------------------------------------------------------------
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-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 15.500000 1162.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 11 21.500000 1612.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 9.000000 499.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 24 46.000000 2553.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
SCREEN-T1023-SCREENING 5 5.000000 250.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 52 138.250000 8487.6000 61.3931
-----------------------------------------------------------------------------------------------------------------------
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 55 247.000000 12350.0000 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 4 32.000000 2286.0800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 4 18.000000 1285.9200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 7 35.750000 2553.9800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 45.500000 3250.5200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 26.000000 1857.4400 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) 356 7963.250000 73081.3200 9.1773
-----------------------------------------------------------------------------------------------------------------------
Total 9098.250000 117976.9200 12.9670
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 768
-----------------------------------------------------------------------------------------------------------------------
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 2358 7576.000000 61283.7300 61012.9500
292 280.500000 6889.8000 0.0000
Other 2474 1241.750000 49803.3900 0.0000
---------------------------------------------------------
Total 5124 9098.250000 117976.9200 61012.9500