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
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 682 432.500000 16002.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 9 6.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 499 1664.250000 61577.2500 37.0000
Subtotal (Total Children Is Unduplicated) 940 2103.000000 77579.7500 36.8900
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.000000 97.0000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 13 12.000000 600.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 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 1 1.500000 112.5000 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 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 50 91.000000 6825.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 38 67.500000 5062.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 32 58.000000 4350.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 69 129.000000 7159.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 42.000000 3150.0000 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
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 155 436.000000 29244.8900 67.0754
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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 91.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 115 380.750000 19037.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 119 307.250000 15362.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 93 293.000000 2930.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 18.000000 1285.9200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 2 2.750000 196.4600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 6 22.000000 1413.3300 64.2423
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 21 40.000000 2857.6000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 8 12.750000 910.8600 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) 618 22340.00000 80006.9900 3.5813
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Total 24879.000000 186831.6300 7.5096
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Number of Children (Unduplicated) With at Least One Service 1189
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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 0 0.000000 0.0000 0.0000
P 1970 16525.750000 51198.2300 51198.2300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 124 1173.250000 2356.1300 2356.1300
T 0 0.000000 0.0000 0.0000
5111 7180.000000 133277.2700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7205 24879.000000 186831.6300 53554.3600