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
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 617 391.000000 14467.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 32 25.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1578 7609.500000 281542.2500 36.9988
Subtotal (Total Children Is Unduplicated) 1628 8025.500000 296009.2500 36.8836
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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 12 15.000000 1125.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 5.000000 375.0000 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 7 9.500000 712.5000 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 12 14.500000 804.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 44 60.500000 4537.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 189 238.000000 17850.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 11.000000 825.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 74 88.500000 6637.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 14.000000 1050.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 86 108.500000 8137.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 51 69.500000 3857.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 295 376.500000 20895.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 6.500000 487.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 60 79.500000 5962.5000 75.0000
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 14 14.000000 714.7000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 12 12.000000 612.6000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 6 6.000000 306.3000 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 15 15.000000 765.7500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 459.4500 51.0500
Subtotal (Total Children Is Unduplicated) 484 1189.500000 78253.5500 65.7869
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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 51 52.000000 2600.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 91 95.000000 4750.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 24 35.250000 1762.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 47 47.000000 2350.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 150 151.000000 7550.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 2.000000 50.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 11 216.000000 5400.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 778 5457.000000 272850.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 231 1107.750000 55387.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 779 5743.000000 57430.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 2.000000 142.8800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 10 24.500000 1750.2800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 8 37.000000 2116.4000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 3 13.000000 743.6000 57.2000
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 4.000000 285.7600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 10 43.000000 3071.9200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 3 9.500000 678.6800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 15 92.500000 5287.3000 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 4 16.500000 943.1400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 21 129.500000 9251.4800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 21 85.750000 6125.9800 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 28.500000 1630.2000 57.2000
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) 966 15774.25000 444534.7100 28.1810
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Total 24989.250000 818797.5100 32.7660
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Number of Children (Unduplicated) With at Least One Service 1747
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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 740 903.000000 34858.5600 148.0000
P 3728 4383.750000 180274.9400 179122.1900
D 0 0.000000 0.0000 0.0000
S 4 5.000000 90.0000 90.0000
H 0 0.000000 0.0000 0.0000
T 2910 10819.000000 198305.6100 198295.6100
5412 8848.250000 404130.9900 246648.7700
Other 12 21.500000 813.6600 813.6600
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Total 12814 24989.250000 818797.5100 625118.2300