CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2021 ending 03/31/2021 Date of Report:05/04/2021 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 1041 1787.750000 66063.7500 36.9536
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 18 13.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 359 778.750000 28804.5000 36.9881
Subtotal (Total Children Is Unduplicated) 1157 2580.250000 94868.2500 36.7671
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 4 7.000000 350.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 27 51.500000 2575.0000 50.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 6.000000 450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 9 14.500000 1087.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 9.500000 712.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 19 34.000000 1887.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 15.000000 1125.0000 75.0000
Subtotal (Total Children Is Unduplicated) 55 140.500000 8412.0000 59.8719
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 7 3.750000 187.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 22 15.500000 775.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 15 6.250000 312.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 216 247.250000 12338.0000 49.9009
CONOF-CONOF-CONSULT, OT, FACE TO FACE 8 5.750000 287.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 168 125.000000 6250.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 5.000000 250.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 127 65.000000 3250.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 21 15.750000 762.5000 48.4127
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 127 108.750000 5437.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.500000 37.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 12 26.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 3.000000 150.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 34 139.000000 6950.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 10 16.000000 160.0000 10.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 4 7.500000 535.8000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 6.000000 428.6400 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 33 50.500000 1868.5000 37.0000
TRAV-TRAVS-Travel by mile 5 66.000000 29.3500 0.4447
Subtotal (Total Children Is Unduplicated) 342 915.750000 40106.7300 43.7966
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Total 3636.500000 143386.9800 39.4299
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Number of Children (Unduplicated) With at Least One Service 1212
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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 3 0.750000 34.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 28 23.500000 869.5000 0.0000
S 10 4.000000 200.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 59 58.500000 2944.2500 2869.2500
6144 3549.750000 139338.9800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6244 3636.500000 143386.9800 2869.2500