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
Payclass Filters:GR
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 384 1127.750000 41726.7500 37.0000
Subtotal (Total Children Is Unduplicated) 603 1270.500000 47008.5000 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-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 3.500000 262.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.000000 75.0000 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 12 22.000000 1650.0000 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 26 44.000000 3300.0000 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
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 89.3400 44.6700
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 25.7900 25.7900
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 12 12.000000 612.6000 51.0500
Subtotal (Total Children Is Unduplicated) 113 291.500000 18994.8800 65.1625
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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 165 852.250000 42612.5000 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 21 150.750000 9538.5200 63.2738
OCCT-97530GT-OT SESSION BY LICENSED OT 2 13.000000 928.7200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 3 9.500000 365.6700 38.4916
PHY-97110GT-PT SESSION BY LICENSED PT 3 30.000000 2143.2000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 33 110.750000 7094.5400 64.0591
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 15.500000 1107.3200 71.4400
TRAV-TRAVS-Travel by mile 299 17474.00000 7772.9600 0.4448
Subtotal (Total Children Is Unduplicated) 593 22763.75000 123614.6800 5.4303
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Total 24325.750000 189618.0600 7.7950
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Number of Children (Unduplicated) With at Least One Service 866
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Center 05
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 4039 22676.250000 137486.1400 137486.1400
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
2192 1649.500000 52131.9200 5073.4200
Other 0 0.000000 0.0000 0.0000
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Total 6231 24325.750000 189618.0600 142559.5600