CMS/EIP Fiscal Report Center: 52
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 459 286.750000 10563.7500 36.8396
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 17 4.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 769 2590.250000 95509.2500 36.8726
Subtotal (Total Children Is Unduplicated) 815 2881.250000 106073.0000 36.8149
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 11 21.500000 1612.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 10.000000 750.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 9 17.500000 971.2500 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 185 375.000000 27275.0000 72.7333
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 109 221.000000 16125.0000 72.9638
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 40 83.500000 5932.5000 71.0479
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 28 56.000000 3108.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 156 308.000000 17094.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 14.000000 1050.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 7 7.000000 357.3500 51.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
SCREEN-T1023-SCREENING 33 33.000000 1650.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 16 18.000000 888.2400 49.3467
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 12 12.000000 612.6000 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 272 1195.500000 78562.3400 65.7150
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 42 44.000000 2200.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 73 78.750000 3937.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 23 18.000000 450.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 61 97.250000 4862.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 23 29.250000 1450.0000 49.5726
CONIP-CONIP-CONSULT, ITDS PHONE 8 4.500000 112.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 49 73.250000 3662.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 25 21.750000 1087.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.500000 12.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 25 26.500000 1325.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 6 3.250000 162.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 59 71.250000 3562.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 21 18.750000 937.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.500000 12.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 59 74.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 266 1433.000000 71490.0000 49.8883
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 67 193.000000 9550.0000 49.4819
INTR-T1013-INTERPRETER 3 29.000000 1450.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 492 3540.000000 35382.0000 9.9949
OCCT-97530-OT SESSION BY LICENSED OT 33 114.500000 7769.1000 67.8524
OCCT-97530GT-OT SESSION BY LICENSED OT 10 20.750000 1339.5000 64.5542
OCCT-97530HM-OT SESSION BY OT ASST 10 29.500000 1401.4000 47.5051
OCCT-97530HMGT-OT SESSION BY OT ASST 2 3.500000 200.2000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 37 197.750000 14127.2600 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 15 28.500000 2036.0400 71.4400
OCCT-97530TLGTHM-OT SESSION BY OT ASST 3 4.500000 257.4000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 7 14.500000 829.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 35 203.250000 12984.2200 63.8830
PHY-97110GT-PT SESSION BY LICENSED PT 2 7.500000 321.4800 42.8640
PHY-97110TL-PT SESSION BY LICENSED PT 31 173.000000 12359.1200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 142 953.250000 63077.3100 66.1708
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 22 64.000000 4362.1200 68.1581
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 87 399.250000 28522.4200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 5 26.500000 1893.1600 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 1 0.750000 27.7500 37.0000
TRAV-TRAVS-Travel by mile 415 36057.00000 16043.2700 0.4449
Subtotal (Total Children Is Unduplicated) 630 44055.75000 309223.1500 7.0189
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Total 48132.500000 493858.4900 10.2604
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Number of Children (Unduplicated) With at Least One Service 880
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Center 52
Flag Claims Units Chgs Paid
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R 6 6.250000 307.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 449 478.250000 24824.6200 0.0000
P 1622 1741.250000 78035.5900 77257.0600
D 106 137.000000 7334.8200 0.0000
S 439 433.250000 17718.9600 188.8000
H 104 132.000000 8646.2300 40.0000
T 4183 41367.750000 159293.9000 151992.2300
3281 3836.750000 197697.1200 86.8700
Other 0 0.000000 0.0000 0.0000
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Total 10190 48132.500000 493858.4900 229564.9600