CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
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 746 839.750000 31070.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 32 33.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 643 1203.750000 44538.7500 37.0000
Subtotal (Total Children Is Unduplicated) 830 2076.500000 75609.5000 36.4120
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 29 46.250000 2312.5000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 8.500000 471.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 13.000000 975.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 49 96.000000 7200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 17 30.000000 1665.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 63 117.000000 6493.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 43 86.500000 6487.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 21.1400 21.1400
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 357.3500 51.0500
Subtotal (Total Children Is Unduplicated) 162 433.250000 27857.5900 64.2991
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 629.4600 314.7300
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 11 11.750000 587.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 34 40.500000 2025.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 4.000000 100.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 61 96.000000 4800.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 103 249.750000 12487.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 52 80.250000 4012.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 3 4.750000 237.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 31 55.000000 2750.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 73 105.250000 5262.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 78 531.000000 26550.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 54 190.500000 9525.0000 50.0000
INTR-T1013-INTERPRETER 18 85.750000 4287.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 309 1998.000000 19980.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 21 100.000000 6130.6100 61.3061
OCCT-97530GT-OT SESSION BY LICENSED OT 2 13.500000 402.0400 29.7807
PHY-97110-PT SESSION BY LICENSED PT 15 60.500000 2646.0900 43.7370
PHY-97110GT-PT SESSION BY LICENSED PT 4 16.500000 995.7800 60.3503
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 46 251.500000 16907.6300 67.2272
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 9 34.250000 2446.8200 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 6 5.250000 194.2500 37.0000
TRAV-TRAVS-Travel by mile 148 12732.00000 5664.5500 0.4449
Subtotal (Total Children Is Unduplicated) 439 16672.00000 128772.2300 7.7239
-----------------------------------------------------------------------------------------------------------------------
Total 19181.750000 232239.3200 12.1073
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 911
-----------------------------------------------------------------------------------------------------------------------
Center 02
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 16 15.500000 345.7200 345.7200
H 0 0.000000 0.0000 0.0000
T 4364 14050.500000 123690.9500 123563.9500
151 2381.500000 3286.7700 0.0000
Other 4517 2734.250000 104915.8800 0.0000
---------------------------------------------------------
Total 9048 19181.750000 232239.3200 123909.6700