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
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 746 839.750000 31070.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 32 33.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 171 317.000000 11729.0000 37.0000
Subtotal (Total Children Is Unduplicated) 779 1189.750000 42799.7500 35.9737
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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 4 8.000000 600.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.500000 187.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 13 24.500000 1837.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 9.500000 527.2500 55.5000
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 12 22.500000 1687.5000 75.0000
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 70 156.250000 9573.3000 61.2691
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EI Services,Class #03
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 13 56.000000 2800.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 19 53.000000 2650.0000 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 2 5.250000 375.0600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 2 3.750000 267.9000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 22.750000 1625.2600 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) 409 15613.00000 70257.0200 4.4999
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Total 16959.000000 122630.0700 7.2310
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Number of Children (Unduplicated) With at Least One Service 864
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Center 02
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 12 12.000000 160.0000 160.0000
H 0 0.000000 0.0000 0.0000
T 3129 13025.750000 66084.1100 66084.1100
137 2364.250000 2107.8300 0.0000
Other 2844 1557.000000 54278.1300 0.0000
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Total 6122 16959.000000 122630.0700 66244.1100