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: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 380 157.500000 5827.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1086 3293.500000 121859.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1088 3451.000000 127687.0000 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 21 36.500000 2737.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 28 45.000000 3375.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 30.000000 2250.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 13.000000 975.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 62 88.500000 6637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 37 66.500000 3690.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 25 37.500000 2081.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 4.000000 300.0000 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) 175 415.500000 27500.1400 66.1857
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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 566 3839.000000 38390.0000 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 303 17515.00000 7791.1900 0.4448
Subtotal (Total Children Is Unduplicated) 609 23099.75000 141409.7500 6.1217
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Total 26966.250000 296596.8900 10.9988
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Number of Children (Unduplicated) With at Least One Service 1127
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Center 05
Flag Claims Units Chgs Paid
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R 5 3.750000 233.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2821 2048.250000 78415.1600 13449.5050
P 4241 23038.500000 156837.4600 156837.4600
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
2440 1875.750000 61110.5200 6457.7700
Other 0 0.000000 0.0000 0.0000
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Total 9507 26966.250000 296596.8900 176744.7350