CMS/EIP Fiscal Report Center: 55
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 1057 1170.250000 43299.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 33 23.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1100 3691.500000 136563.3000 36.9940
Subtotal (Total Children Is Unduplicated) 1176 4885.250000 179862.5500 36.8175
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 20 32.000000 1600.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 2 4.000000 200.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 34 57.000000 2850.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 9 18.000000 1350.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 18.000001 1350.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 272 546.000000 40950.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 18.000000 1350.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 106 216.000000 16200.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 47 93.999999 7050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 17 34.000000 1887.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 75 151.000000 8380.5000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 9 9.000000 459.4500 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 6 6.000000 306.3000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 23 23.000000 1174.1500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 22 22.000000 1123.1000 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 97.8800 48.9400
Subtotal (Total Children Is Unduplicated) 425 1286.000000 88489.1800 68.8096
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.000000 158.1200 79.0600
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 3 4.000000 200.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 18 16.250000 812.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 72 72.000000 1800.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 34 59.000000 2950.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 39 110.000000 2750.0000 25.0000
CONPP-CONPP-CONSULT, PT, PHONE 7 3.500000 87.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 14 11.750000 587.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 62 52.500000 1312.5000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 14.000000 350.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 283 1650.500000 82525.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 70 260.000000 13000.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 578 4602.000000 46020.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 106 578.500000 41345.9000 71.4709
OCCT-97530GT-OT SESSION BY LICENSED OT 8 22.000000 1571.6800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 104 777.500000 44473.0000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 17 116.000000 6635.2000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 13 51.000000 3643.4400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 7.000000 500.0800 71.4400
OCCT-97530TLGTHM-OT SESSION BY OT ASST 2 11.000000 629.2000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 1 2.000000 114.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 33 175.749995 12555.5800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 4 14.000000 1000.1600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 43 256.250000 14647.2500 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 9 38.250000 2186.3700 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 4 10.000000 714.4000 71.4400
PHY-97110TLGTHM-PT SESSION BY PT ASST 3 14.000000 800.2400 57.1600
PHY-97110TLHM-PT SESSION BY PT ASST 7 33.000000 1886.2800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 213 1166.500000 83334.7600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 13 105.500000 7536.9200 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 52 264.500000 18895.8800 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 4 25.000000 1786.0000 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 1 0.500000 18.5000 37.0000
TRAV-TRAVS-Travel by mile 69 3599.000000 1601.0800 0.4449
Subtotal (Total Children Is Unduplicated) 660 14125.75000 398479.4400 28.2094
-----------------------------------------------------------------------------------------------------------------------
Total 20296.999995 666831.1700 32.8537
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1192
-----------------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3404 2934.500000 127662.3200 0.0000
P 6420 8923.947774 149335.2200 170749.5200
D 0 0.000000 0.0000 0.0000
S 1 0.836800 62.7600 0.0000
H 46 80.500000 5929.7300 0.0000
T 0 0.000000 0.0000 0.0000
9630 8357.215421 383841.1400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 19501 20296.999995 666831.1700 170749.5200