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:OTHER
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 1 0.500000 18.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 161 335.000000 12376.5000 36.9448
Subtotal (Total Children Is Unduplicated) 161 335.500000 12395.0000 36.9449
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 11.500000 862.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 10 16.000000 888.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 49 74.000000 5475.0000 73.9865
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 31 54.500000 4087.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 80 128.000000 7076.2500 55.2832
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 95 295.000000 19142.4000 64.8895
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 8 8.000000 400.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 8 12.500000 625.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 21 26.000000 650.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 1 2.000000 100.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 4.000000 200.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 154 933.000000 46650.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 67 253.000000 12650.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 38 211.500000 15109.5600 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 12 69.000000 4929.3600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 59 460.500000 32898.1200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 7 29.000000 2071.7600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 122 796.500000 56901.9600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 21 135.000000 9644.4000 71.4400
TRAV-TRAVS-Travel by mile 404 30942.00000 13557.1500 0.4381
Subtotal (Total Children Is Unduplicated) 592 33889.00000 196712.3100 5.8046
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Total 34519.500000 228249.7100 6.6122
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Number of Children (Unduplicated) With at Least One Service 729
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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 1016 20418.500000 129131.0400 129131.0400
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 607 13473.500000 67834.4200 67834.4200
186 195.500000 7285.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2079 34519.500000 228249.7100 196965.4600