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: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 824 909.000000 33633.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1501 7571.500000 280008.7500 36.9819
Subtotal (Total Children Is Unduplicated) 1553 8480.500000 313641.7500 36.9839
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 52 57.000000 2850.0000 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 19 21.500000 1612.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 20 32.000000 2400.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 40 76.500000 4245.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 88 95.000000 7125.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 177 197.500000 14812.5000 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 296 582.000000 32301.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 147 195.500000 14633.2500 74.8504
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 85 86.000000 8497.5200 98.8084
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) 430 1407.500000 92043.8600 65.3953
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 814 5683.000000 284150.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 167 933.750000 46687.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 815 5874.000000 58740.0000 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) 1013 13328.00000 442946.8400 33.2343
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Total 23216.000000 848632.4500 36.5538
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Number of Children (Unduplicated) With at Least One Service 1783
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Center 04
Flag Claims Units Chgs Paid
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R 87 135.250000 5061.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2518 4067.250000 159728.7500 0.0000
P 3024 8964.750000 199665.9400 194688.1400
D 97 160.250000 6314.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1618 5888.000000 297573.2700 870.0800
T 0 0.000000 0.0000 0.0000
3621 3776.000000 166114.4600 0.0000
Other 87 224.500000 14174.7800 1657.2800
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Total 11052 23216.000000 848632.4500 197215.5000