CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 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 1420 896.500000 33170.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 40 27.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 803 2541.750000 94044.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1714 3466.000000 127215.2500 36.7038
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 5 8.000000 400.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 26.500000 1987.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 10 16.000000 1200.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 11.500000 862.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 10.500000 787.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 24.500000 1359.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 8 12.500000 693.7500 55.5000
Subtotal (Total Children Is Unduplicated) 38 117.000000 7853.5000 67.1239
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 31 29.500000 1450.0000 49.1525
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 7 7.000000 350.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 33 29.250000 731.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 4 3.000000 118.7500 39.5833
CONIP-CONIP-CONSULT, ITDS PHONE 10 13.000000 275.0000 21.1538
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 7 9.250000 181.2500 19.5946
CONPP-CONPP-CONSULT, PT, PHONE 2 1.500000 37.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 1.000000 50.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 6 9.000000 225.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 240 1495.250000 74162.5000 49.5987
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 119 485.500000 24150.0000 49.7425
INTR-T1013-INTERPRETER 9 98.000000 7420.0000 75.7143
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 885 6205.000000 62010.0000 9.9936
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 7 19.500000 1321.6400 67.7764
PHY-97110-PT SESSION BY LICENSED PT 9 17.750000 1268.0600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 4 9.500000 678.6800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 34.500000 2464.6800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 9 23.500000 1677.2400 71.3719
SPL-92508-GROUP SPL SESSION PER CHILD 3 57.500000 638.4800 11.1040
Subtotal (Total Children Is Unduplicated) 974 8550.500000 179331.4700 20.9732
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Total 12133.500000 314400.2200 25.9118
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Number of Children (Unduplicated) With at Least One Service 2029
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Center 06
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 6736 6709.500000 144188.2500 144188.2500
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
8552 5424.000000 170211.9700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 15288 12133.500000 314400.2200 144188.2500