CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/21/2020 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 495 300.250000 11036.5000 36.7577
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7 3.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 314 1043.750000 38535.5000 36.9202
Subtotal (Total Children Is Unduplicated) 638 1347.250000 49572.0000 36.7950
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 6 15.000000 934.0500 62.2700
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 19 17.750000 887.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 83 106.500000 5325.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 83 89.500000 2237.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 44 60.000000 3000.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 87 158.500000 7925.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 11 5.750000 143.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 28 23.500000 1175.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 62 92.750000 4637.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 5 2.500000 62.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 9 11.000000 550.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 28 30.000000 1500.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 5 3.500000 87.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 18 20.000000 1000.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 46 66.250000 3312.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 10 6.250000 156.2500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 29 34.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 26.000000 1300.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 11 39.500000 1975.0000 50.0000
INTR-T1013-INTERPRETER 5 35.000000 1750.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 335 1021.000000 10210.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 2 6.000000 428.6400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 3.500000 250.0400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 357.2000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 7 27.500000 1964.6000 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 16 19.250000 712.2500 37.0000
TRAV-TRAVS-Travel by mile 280 11035.00000 4909.5600 0.4449
Subtotal (Total Children Is Unduplicated) 478 12947.00000 55928.7300 4.3198
-----------------------------------------------------------------------------------------------------------------------
Total 14309.250000 106434.7800 7.4382
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 777
-----------------------------------------------------------------------------------------------------------------------
Center 52
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 9 7.500000 314.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 1955 12900.500000 55709.7800 53675.5100
1994 1401.250000 50410.5000 92.5000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3958 14309.250000 106434.7800 53768.0100