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
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 1057 1170.250000 43299.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 33 23.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 307 995.500000 36833.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1095 2189.250000 80132.7500 36.6028
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 17 26.000000 1300.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 2 4.000000 200.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 33 55.000000 2750.0000 50.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.771467 282.8600 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 21 37.446400 2808.4800 75.0000
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 12 23.071733 1730.3800 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 13 25.819820 1433.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 0.539275 27.5300 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 48.9400 48.9400
Subtotal (Total Children Is Unduplicated) 102 202.648695 12153.4900 59.9732
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EI Services,Class #03
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 17 15.250000 762.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 72 72.000000 1800.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 32 55.000000 2750.0000 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 2 9.000000 225.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 81 474.000000 23700.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 21 93.250000 4662.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 578 4590.000000 45900.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 27.324045 1952.0300 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 7 27.761711 1587.9700 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 3.315910 189.6700 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1 4.443165 317.4200 71.4401
PHY-97110HM-PT SESSION BY PT ASST 4 21.361092 1221.0000 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 0.739678 42.2800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 34 138.526600 9896.3400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 49.678606 3549.0400 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 1 0.500000 18.5000 37.0000
TRAV-TRAVS-Travel by mile 69 3588.000000 1596.1900 0.4449
Subtotal (Total Children Is Unduplicated) 621 9352.900807 105157.9400 11.2434
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Total 11744.799502 197444.1800 16.8112
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Number of Children (Unduplicated) With at Least One Service 1144
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Center 55
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 5300 7875.979615 90388.1000 90388.1000
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 0 0.000000 0.0000 0.0000
5242 3868.819887 107056.0800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 10542 11744.799502 197444.1800 90388.1000