CMS/EIP Fiscal Report Center: 09
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 1805 5559.500000 205701.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5 2.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1791 6410.000000 236874.0000 36.9538
Subtotal (Total Children Is Unduplicated) 1997 11972.00000 442575.5000 36.9675
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 18 31.000000 2325.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 11 21.000000 1575.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 11 21.500000 1573.5000 73.1860
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 5 8.500000 637.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 30 55.500000 2899.8800 52.2501
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 221 407.000000 30305.0000 74.4595
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 143 275.500000 20617.5000 74.8367
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 132 259.000000 19425.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 385 723.000000 39398.2900 54.4928
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 51 99.000000 7425.0000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 8 33.000000 1650.0000 50.0000
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
SPCH-92610GT-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 518 1955.000000 128990.9200 65.9800
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 66.5000 66.5000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 72 119.500000 5962.5000 49.8954
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 44 75.000000 3750.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 114 160.500000 4012.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 13 14.000000 700.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 10 18.750000 937.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 5.500000 137.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 19 29.000000 1450.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 4 5.000000 250.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 10.000000 500.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 4 4.000000 200.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 19 21.500000 1075.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 8 9.000000 450.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 4 7.000000 175.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 793 5859.000000 292950.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 245 1227.000000 61350.0000 50.0000
INTR-T1013-INTERPRETER 51 99.250000 4962.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 33 188.000000 1880.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 140 899.000000 63377.5700 70.4979
OCCT-97530GT-OT SESSION BY LICENSED OT 22 114.750000 8197.7400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 6 40.500000 2893.3200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 163 1192.000000 84142.9300 70.5897
PHY-97110GT-PT SESSION BY LICENSED PT 30 120.500000 8608.5200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 378 3102.750000 220250.6900 70.9856
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 93 523.000000 37000.8900 70.7474
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 5 27.000000 1928.8800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.000000 55.5200 13.8800
TRAV-TRAVS-Travel by mile 744 81128.00000 35627.4200 0.4392
Subtotal (Total Children Is Unduplicated) 1359 95005.50000 842917.4800 8.8723
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Total 108932.500000 1414483.9000 12.9850
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Number of Children (Unduplicated) With at Least One Service 2091
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Center 09
Flag Claims Units Chgs Paid
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R 12 10.500000 370.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 800 878.250000 33354.5000 0.0000
P 11942 67069.750000 682788.0100 683251.8700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 270 432.000000 23998.7500 0.0000
T 4580 33382.750000 262747.4300 261681.1800
2211 6746.750000 382276.7100 0.0000
Other 211 412.500000 28948.5000 0.0000
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Total 20026 108932.500000 1414483.9000 944933.0500