CMS/EIP Fiscal Report Center: 57
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 842 459.250000 16992.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 64 97.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 662 3259.250000 120592.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1217 3816.250000 137584.5000 36.0523
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 3 3.000000 150.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.000000 450.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.000000 388.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 9.000000 675.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 15.500000 860.2500 55.5000
Subtotal (Total Children Is Unduplicated) 21 50.500000 3244.5000 64.2475
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 14 14.000000 700.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 86 84.000000 4200.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 3 3.000000 75.0000 25.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 4 4.000000 200.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 143 138.000000 6900.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 4 3.500000 87.5000 25.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 74 389.500000 19475.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 35 97.000000 970.0000 10.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 1 4.000000 285.7600 71.4400
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110GT-PT SESSION BY LICENSED PT 1 0.500000 35.7200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 25.500000 1821.7200 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 117 231.500000 8565.5000 37.0000
Subtotal (Total Children Is Unduplicated) 397 996.500000 43423.4000 43.5759
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Total 4863.250000 184252.4000 37.8867
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Number of Children (Unduplicated) With at Least One Service 1346
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Center 57
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 4 1.000000 37.0000 37.0000
D 2 1.750000 64.7500 64.7500
S 5 5.500000 242.5000 242.5000
H 0 0.000000 0.0000 0.0000
T 697 987.500000 43025.4000 43025.4000
4704 3866.000000 140827.2500 100.0000
Other 2 1.500000 55.5000 55.5000
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Total 5414 4863.250000 184252.4000 43525.1500