CMS/EIP Fiscal Report Center: 57
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 554 351.750000 13014.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 32 25.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 530 2500.000000 92490.7500 36.9963
Subtotal (Total Children Is Unduplicated) 896 2876.750000 105505.5000 36.6752
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 8 8.000000 400.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 7 10.000000 500.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 14.000000 1050.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 9.500000 712.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 15.500000 860.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 6 9.000000 499.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 7.000000 525.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 53 109.500000 6752.5500 61.6671
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 4.750000 237.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 0.500000 12.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 50 51.000000 2550.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 91 95.000000 4750.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 24 34.250000 1712.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 47 47.000000 2350.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 149 150.000000 7500.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 75 461.000000 23050.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 15 77.000000 3850.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 779 5734.000000 57340.0000 10.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 2 2.500000 178.6000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 8.000000 457.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 2 15.000000 1071.6000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 4 23.000000 1314.6800 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 9.000000 514.4400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 21.000000 1500.2400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 22.000000 1571.6800 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 7 29.250000 1082.2500 37.0000
TRAV-TRAVS-Travel by mile 9 2348.000000 1044.8400 0.4450
Subtotal (Total Children Is Unduplicated) 845 9135.250000 112209.8700 12.2832
-----------------------------------------------------------------------------------------------------------------------
Total 12121.500000 224467.9200 18.5182
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1333
-----------------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 3 4.000000 40.0000 40.0000
H 0 0.000000 0.0000 0.0000
T 2361 9138.750000 112529.4900 112519.4900
3302 2978.750000 111898.4300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5666 12121.500000 224467.9200 112559.4900