CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2020 ending 09/30/2020 Date of Report:10/15/2020 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 946 1797.000000 66470.5000 36.9897
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 12 8.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 312 883.250000 32662.5000 36.9799
Subtotal (Total Children Is Unduplicated) 1037 2689.000000 99133.0000 36.8661
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
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 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 10 20.500000 1137.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 9.500000 712.5000 75.0000
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 14 43.500000 2812.7500 64.6609
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 1.250000 62.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 14 11.750000 587.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 29 13.750000 687.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 259 278.750000 13937.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 3.250000 75.0000 23.0769
CONOF-CONOF-CONSULT, OT, FACE TO FACE 14 8.500000 425.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 214 145.500000 7275.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 27 15.250000 762.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 153 85.750000 4287.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 18 8.000000 400.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 232 210.000000 10487.5000 49.9405
CONSP-CONSP-CONSULT, SLP, PHONE 3 2.500000 62.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 6.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 6.000000 300.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 27 106.250000 5312.5000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 7 25.000000 1786.0000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 5.750000 410.7800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 16.000000 1143.0400 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 69 79.250000 2932.2500 37.0000
TRAV-TRAVS-Travel by mile 1 42.000000 18.6900 0.4450
Subtotal (Total Children Is Unduplicated) 375 1073.500000 51028.2600 47.5345
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Total 3806.000000 152974.0100 40.1929
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Number of Children (Unduplicated) With at Least One Service 1084
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Center 53
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 1 0.750000 27.7500 9.2500
D 19 12.250000 453.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 81 119.500000 3934.0200 3884.0200
6686 3673.500000 148558.9900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6787 3806.000000 152974.0100 3893.2700