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
Agency Filter:EIP DEI DEIP
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 1441 6692.250000 247604.0000 36.9986
Subtotal (Total Children Is Unduplicated) 1490 7069.000000 260618.7500 36.8678
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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 3 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 10 12.000000 900.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 6 8.000000 600.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.500000 194.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 10 11.500000 638.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 37 50.000000 3750.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 150 189.000000 14175.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 47 57.500000 4312.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 9.000000 675.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 66 84.500000 6337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 37 50.500000 2802.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 225 290.000000 16095.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 5.500000 412.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 45 59.500000 4462.5000 75.0000
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 348 871.000000 57846.9500 66.4144
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EI Services,Class #03
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 2 4.000000 200.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 2 7.000000 350.0000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 5 9.000000 642.9600 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 4.000000 285.7600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 1.250000 89.3000 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 1 0.500000 18.5000 37.0000
Subtotal (Total Children Is Unduplicated) 12 25.750000 1586.5200 61.6124
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Total 7965.750000 320052.2200 40.1785
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Number of Children (Unduplicated) With at Least One Service 1493
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Center 57
Flag Claims Units Chgs Paid
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R 8 8.750000 323.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 641 728.250000 27939.3100 148.0000
P 3449 3963.000000 161258.1900 160153.5400
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
3519 3265.750000 130530.9700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7617 7965.750000 320052.2200 160301.5400