CMS/EIP Fiscal Report Center: 03
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 682 432.500000 16002.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 9 6.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1266 3954.000000 146298.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1291 4392.750000 162300.5000 36.9474
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 3 3.000000 145.5000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 13 12.000000 600.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 10.000000 750.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 8.500000 637.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 2.500000 138.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 8.500000 471.7500 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 143 252.500000 18937.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 111 194.500000 14587.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 88 159.000000 11925.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 15.000000 832.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 105 191.500000 10628.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 98 164.000000 12300.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 2.9900 2.9900
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 3 3.000000 150.0000 50.0000
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 8.000000 408.4000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 2 2.000000 102.1000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 48.9400 48.9400
Subtotal (Total Children Is Unduplicated) 327 1069.000000 74902.1800 70.0675
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 48 47.250000 2362.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 93 109.250000 5462.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 25 33.000000 1650.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 88 128.500000 6425.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.500000 12.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 38 50.000000 2500.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 32 44.250000 2212.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 26 25.250000 1262.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 3 3.000000 150.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 55 63.000000 3150.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 29 30.750000 1537.5000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 63 92.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 119 390.750000 19537.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 191 397.750000 19887.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 93 293.000000 2930.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 42.000000 2889.0600 68.7871
OCCT-97530GT-OT SESSION BY LICENSED OT 9 22.500000 1607.4000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 10 17.500000 1250.2000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 29 86.250000 6003.3500 69.6041
PHY-97110GT-PT SESSION BY LICENSED PT 10 15.000000 1071.6000 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 9 14.000000 1000.1600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 2 8.000000 571.5200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 57 170.500000 11983.1000 70.2821
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 38 67.000000 4786.4800 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 5 17.250000 1232.3400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 10 27.000000 1928.8800 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 3 2.250000 83.2500 37.0000
TRAV-TRAVS-Travel by mile 345 20634.00000 9179.5700 0.4449
Subtotal (Total Children Is Unduplicated) 732 22832.50000 112691.9100 4.9356
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Total 28294.250000 349894.5900 12.3663
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Number of Children (Unduplicated) With at Least One Service 1401
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Center 03
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 3664 2743.250000 116992.6700 0.0000
P 2047 16602.000000 55358.4300 55311.4300
D 53 33.750000 1248.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 126 1175.750000 2518.6300 2518.6300
T 0 0.000000 0.0000 0.0000
5557 7739.500000 173776.1100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11447 28294.250000 349894.5900 57830.0600