CMS/EIP Fiscal Report Center: 52
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 450 283.750000 10452.7500 36.8379
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 16 4.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 304 980.750000 36130.5000 36.8397
Subtotal (Total Children Is Unduplicated) 591 1268.500000 46583.2500 36.7231
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 355.0000 59.1667
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 12 31.000000 1815.0000 58.5484
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 42 44.000000 2200.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 73 78.750000 3937.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 23 18.000000 450.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 61 97.250000 4862.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 23 29.250000 1450.0000 49.5726
CONIP-CONIP-CONSULT, ITDS PHONE 8 4.500000 112.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 49 71.250000 3562.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 25 21.750000 1087.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.500000 12.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 25 26.500000 1325.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 6 3.250000 162.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 59 71.250000 3562.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 21 18.250000 912.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.500000 12.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 57 72.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 12 45.000000 2250.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 9.500000 475.0000 50.0000
INTR-T1013-INTERPRETER 3 29.000000 1450.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 492 3540.000000 35382.0000 9.9949
OCCT-97530-OT SESSION BY LICENSED OT 2 8.000000 571.5200 71.4400
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1 5.500000 392.9200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 12.000000 857.2800 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 1 0.750000 27.7500 37.0000
TRAV-TRAVS-Travel by mile 397 35722.00000 15894.2400 0.4449
Subtotal (Total Children Is Unduplicated) 581 39931.00000 81032.9100 2.0293
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Total 41230.500000 129431.1600 3.1392
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Number of Children (Unduplicated) With at Least One Service 768
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Center 52
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 2.000000 111.0000 52.2800
D 9 12.500000 662.5000 0.0000
S 156 140.250000 5115.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 3449 39786.500000 81009.0400 79619.1600
1994 1289.250000 42533.3700 86.8700
Other 0 0.000000 0.0000 0.0000
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Total 5609 41230.500000 129431.1600 79758.3100