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
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 1805 5559.000000 205683.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5 2.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 687 2574.250000 95090.0000 36.9389
Subtotal (Total Children Is Unduplicated) 1865 8135.750000 300773.0000 36.9693
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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 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 5 9.500000 712.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
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 51 100.000000 7500.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 36 71.500000 5362.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 56 111.500000 8362.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 58 114.500000 6354.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 26.500000 1987.5000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 8 33.000000 1650.0000 50.0000
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH 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
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) 161 487.500000 33211.5000 68.1262
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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 65 111.500000 5562.5000 49.8879
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 38 62.500000 3125.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 98 134.500000 3362.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 12 13.000000 650.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 10 16.750000 837.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 5.500000 137.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 17 27.000000 1350.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 3 3.000000 150.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 6.000000 300.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 3 3.000000 150.0000 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 6.000000 150.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 196 1135.000000 56750.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 78 398.000000 19900.0000 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 61 324.500000 23182.2800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 5 17.750000 1268.0600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 40 224.000000 16002.5600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 5 16.000000 1143.0400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 174 1159.500000 82834.6800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 33 143.000000 10215.9200 71.4400
TRAV-TRAVS-Travel by mile 531 50186.00000 22070.2700 0.4398
Subtotal (Total Children Is Unduplicated) 867 54312.25000 257600.8100 4.7430
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Total 62935.500000 591585.3100 9.3999
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Number of Children (Unduplicated) With at Least One Service 1941
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Center 09
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 7925 43202.500000 407114.9000 407114.9000
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 3872 19687.750000 182010.1600 182019.4100
30 25.250000 960.2500 0.0000
Other 10 20.000000 1500.0000 0.0000
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Total 11837 62935.500000 591585.3100 589134.3100