CMS/EIP Fiscal Report Center: 07
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 1543 2248.750000 83002.7500 36.9106
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 78 87.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 466 1293.000000 47758.2500 36.9360
Subtotal (Total Children Is Unduplicated) 1618 3629.500000 130761.0000 36.0273
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 79 114.000000 5700.0000 50.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 12.000000 665.0000 55.4167
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 58 116.000000 6438.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 27 52.500000 2913.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 49.500000 3712.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 24.000000 1800.0000 75.0000
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 182 374.000000 21553.3500 57.6293
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 33 33.500000 1675.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 38 37.750000 1887.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 23 19.500000 487.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 112 149.500000 7475.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 104 200.000000 10000.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 1.500000 37.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 49 56.250000 2812.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 41 51.250000 2562.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 30 42.750000 2137.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 20 30.750000 1537.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 48 56.500000 2825.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 67 101.000000 5050.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 2.000000 50.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 61 93.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 216 1025.750000 51287.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 69 289.500000 14475.0000 50.0000
INTR-T1013-INTERPRETER 2 7.000000 370.0000 52.8571
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 902 5822.000000 58330.0000 10.0189
OCCT-97530-OT SESSION BY LICENSED OT 9 29.000000 1519.7200 52.4041
OCCT-97530GT-OT SESSION BY LICENSED OT 2 4.000000 247.6500 61.9125
PHY-97110-PT SESSION BY LICENSED PT 2 4.000000 107.2600 26.8150
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 25 125.000000 5915.1900 47.3215
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 7.000000 243.5600 34.7943
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 0.750000 39.1700 52.2267
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 14 21.500000 795.5000 37.0000
TRAV-TRAVS-Travel by mile 22 2630.000000 1170.1200 0.4449
Subtotal (Total Children Is Unduplicated) 1010 10841.75000 173063.1700 15.9627
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Total 14845.250000 325377.5200 21.9180
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Number of Children (Unduplicated) With at Least One Service 1812
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Center 07
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 3337 10862.500000 178907.5200 178907.5200
D 17 16.500000 838.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 8 15.500000 1105.5000 0.0000
T 0 0.000000 0.0000 0.0000
7379 3950.750000 144526.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 10741 14845.250000 325377.5200 178907.5200