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: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 421 1316.500000 48710.5000 37.0000
Subtotal (Total Children Is Unduplicated) 658 1474.000000 54538.0000 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-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 20 34.500000 2587.5000 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 40 60.000000 4500.0000 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
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) 142 363.500000 23848.8800 65.6090
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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 566 3839.000000 38390.0000 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 303 17515.00000 7791.1900 0.4448
Subtotal (Total Children Is Unduplicated) 605 22821.75000 123802.9100 5.4248
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Total 24659.250000 202189.7900 8.1993
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Number of Children (Unduplicated) With at Least One Service 921
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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 4114 22805.250000 142453.3700 142453.3700
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
2427 1854.000000 59736.4200 5148.4200
Other 0 0.000000 0.0000 0.0000
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Total 6541 24659.250000 202189.7900 147601.7900