CMS/EIP Fiscal Report Center: 06
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 1420 896.500000 33170.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 40 27.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2074 6660.750000 246447.7500 37.0000
Subtotal (Total Children Is Unduplicated) 2184 7585.000000 279618.2500 36.8646
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 9 14.500000 725.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 83.2500 55.5000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 106.500000 7987.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 209 336.000000 25161.0000 74.8839
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 21 33.500000 2512.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 65 101.500000 7612.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 18 30.500000 2287.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 85 142.500000 10687.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 63 105.500000 5855.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 176 288.500000 16050.7500 55.6352
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
Subtotal (Total Children Is Unduplicated) 365 1175.500000 79961.0000 68.0230
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 31 29.500000 1450.0000 49.1525
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 7 7.000000 350.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 34 30.250000 756.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 4 3.000000 118.7500 39.5833
CONIP-CONIP-CONSULT, ITDS PHONE 10 13.000000 275.0000 21.1538
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 7 9.250000 181.2500 19.5946
CONPP-CONPP-CONSULT, PT, PHONE 2 1.500000 37.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 1.000000 50.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 6 9.000000 225.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 733 4579.250000 228362.5000 49.8690
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 301 1306.500000 65155.0000 49.8699
INTR-T1013-INTERPRETER 9 98.000000 7420.0000 75.7143
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 885 6205.000000 62010.0000 9.9936
OCCT-97530-OT SESSION BY LICENSED OT 53 223.500000 15529.6500 69.4839
OCCT-97530GT-OT SESSION BY LICENSED OT 17 66.500000 4462.3400 67.1029
OCCT-97530HM-OT SESSION BY OT ASST 11 22.750000 1301.3000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 7 15.750000 900.9000 57.2000
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 0.500000 35.7200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 79 286.250000 19880.6000 69.4519
PHY-97110GT-PT SESSION BY LICENSED PT 31 69.500000 4827.4400 69.4596
PHY-97110HM-PT SESSION BY PT ASST 11 31.500000 1800.5400 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 3 2.000000 114.3200 57.1600
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 152 567.500000 38405.7800 67.6754
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 69 215.250000 15194.1300 70.5883
SPL-92508-GROUP SPL SESSION PER CHILD 4 70.000000 777.2800 11.1040
Subtotal (Total Children Is Unduplicated) 1140 13867.25000 469757.2500 33.8753
-----------------------------------------------------------------------------------------------------------------------
Total 22627.750000 829336.5000 36.6513
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2281
-----------------------------------------------------------------------------------------------------------------------
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 7718 7266.250000 180630.4900 180630.4900
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
20962 15361.500000 648706.0100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 28680 22627.750000 829336.5000 180630.4900