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: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 459 286.750000 10563.7500 36.8396
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 17 4.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 325 1098.000000 40468.7500 36.8568
Subtotal (Total Children Is Unduplicated) 618 1389.000000 51032.5000 36.7405
-----------------------------------------------------------------------------------------------------------------------
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 4 8.000000 505.0000 63.1250
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 6 12.000000 666.0000 55.5000
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 14 39.000000 2337.0000 59.9231
-----------------------------------------------------------------------------------------------------------------------
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 59 74.250000 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 415 36057.00000 16043.2700 0.4449
Subtotal (Total Children Is Unduplicated) 599 40268.00000 81181.9400 2.0160
-----------------------------------------------------------------------------------------------------------------------
Total 41696.000000 134551.4400 3.2270
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 801
-----------------------------------------------------------------------------------------------------------------------
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 2 4.000000 222.0000 111.7600
D 9 12.500000 662.5000 0.0000
S 158 142.750000 5207.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 3477 40125.500000 81458.0700 80048.1900
2084 1411.250000 47001.1200 86.8700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5730 41696.000000 134551.4400 80246.8200