CMS/EIP Fiscal Report Center: 05
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 346 142.750000 5281.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1021 2977.250000 110158.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1023 3120.000000 115440.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 5 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 26 41.500000 2303.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 24.000000 1800.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 19 34.000000 2550.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 28.000000 2100.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 10.500000 787.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 43 67.500000 5062.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 50.000000 2775.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 15 26.000000 1443.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 3.000000 225.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 140.3900 46.7967
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 76.8400 38.4200
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 17 17.000000 834.6600 49.0976
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 140 336.500000 22121.1400 65.7389
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 58 55.250000 2762.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 28 25.750000 1287.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 2.250000 56.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 66 48.000000 2400.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 22 16.750000 837.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 13 8.000000 200.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 18 15.000000 750.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 2 1.500000 75.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 8 6.500000 325.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 9 5.500000 275.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 5 3.000000 75.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 45 29.500000 1475.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 16 12.500000 625.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 7 4.500000 112.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 166 855.250000 42762.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 17 51.000000 2550.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 555 3822.000000 38220.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 29 186.500000 11988.4300 64.2811
OCCT-97530GT-OT SESSION BY LICENSED OT 2 13.000000 928.7200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 21 117.000000 7111.4900 60.7820
PHY-97110GT-PT SESSION BY LICENSED PT 8 62.750000 4482.8600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 49 195.250000 11980.1100 61.3578
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 10 30.000000 2143.2000 71.4400
TRAV-TRAVS-Travel by mile 299 17474.00000 7772.9600 0.4448
Subtotal (Total Children Is Unduplicated) 597 23041.75000 141221.5200 6.1289
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Total 26498.250000 278782.6600 10.5208
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Number of Children (Unduplicated) With at Least One Service 1062
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Center 05
Flag Claims Units Chgs Paid
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R 4 2.750000 158.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2685 1914.750000 73247.6600 12339.5050
P 4166 22909.500000 151870.2300 151870.2300
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 0 0.000000 0.0000 0.0000
2205 1671.250000 53506.0200 6382.7700
Other 0 0.000000 0.0000 0.0000
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Total 9060 26498.250000 278782.6600 170592.5050