CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 Page: 1
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 793 883.000000 32671.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1452 7262.750000 268585.0000 36.9812
Subtotal (Total Children Is Unduplicated) 1503 8145.750000 301256.0000 36.9832
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 51 55.500000 2775.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 17 18.500000 1387.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 18 20.500000 1537.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 19 31.500000 2362.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 39 75.500000 4190.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 80 86.000000 6450.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 159 179.000000 13425.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 267 530.500000 29442.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 131 176.000000 13170.7500 74.8338
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 75 76.000000 7663.3300 100.8333
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 7 7.000000 163.9400 23.4200
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 16 16.000000 816.8000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92521-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 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 397 1295.000000 84583.4200 65.3154
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 810 5673.000000 283650.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 167 933.750000 46687.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 811 5864.000000 58640.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 35 177.000000 12594.8800 71.1575
OCCT-97530GT-OT SESSION BY LICENSED OT 2 8.000000 571.5200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 43 228.000000 13041.6000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 4 23.750000 1358.5000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 27 156.000000 11022.2800 70.6556
PHY-97110HM-PT SESSION BY PT ASST 24 136.000000 7773.7600 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 3.000000 171.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 22 105.500000 6835.3200 64.7898
Subtotal (Total Children Is Unduplicated) 1009 13308.00000 442346.8400 33.2392
-----------------------------------------------------------------------------------------------------------------------
Total 22748.750000 828186.2600 36.4058
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1733
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 83 128.250000 4802.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2397 3867.750000 151319.0000 0.0000
P 2991 8898.250000 197284.4400 192306.6400
D 91 149.750000 5925.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 1615 5884.000000 297373.2700 870.0800
T 0 0.000000 0.0000 0.0000
3452 3596.250000 157307.0200 0.0000
Other 87 224.500000 14174.7800 1657.2800
---------------------------------------------------------
Total 10716 22748.750000 828186.2600 194834.0000