CMS/EIP Fiscal Report Center: 03
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 459 229.250000 8482.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 13 6.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1254 3136.750000 116059.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1283 3372.000000 124542.0000 36.9342
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 10 15.250000 762.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 7.500000 562.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 7.000000 525.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 11.000000 825.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 13.000000 721.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 152 272.500000 20437.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 12.500000 937.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 50 90.500000 6787.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 8.000000 600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 161 287.000000 21525.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 10 16.500000 1237.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 173 325.500000 18065.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 10 17.500000 971.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 138 245.500000 18412.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 14.000000 1050.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97165TL-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97165TLGT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 4 4.000000 224.5900 56.1475
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 13 13.000000 684.0400 52.6185
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 406 1395.750000 96458.2300 69.1085
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 104 111.000000 5550.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 117 109.250000 5462.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 2.000000 50.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 70 89.500000 4475.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 59 71.000000 3550.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 37 47.500000 2375.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 11 15.250000 762.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 19 21.750000 1087.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 9 10.000000 500.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 101 137.000000 6850.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 22 34.000000 1700.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 264 443.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 213 782.250000 39112.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 201 438.500000 21925.0000 50.0000
INTR-T1013-INTERPRETER 7 81.000000 3850.0000 47.5309
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 154 577.000000 5570.0000 9.6534
OCCT-97530-OT SESSION BY LICENSED OT 26 84.000000 5712.6400 68.0076
OCCT-97530GT-OT SESSION BY LICENSED OT 8 12.500000 848.0000 67.8400
OCCT-97530TL-OT SESSION BY LICENSED OT 11 36.000000 2571.8400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 2.500000 178.6000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 38 124.250000 8826.9500 71.0419
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.000000 142.8800 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 22 49.750000 3554.1400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 90 262.500000 18651.2700 71.0525
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 18 20.750000 1482.3800 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 24 55.500000 3964.9200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 6 6.250000 388.9400 62.2304
TRAV-TRAVS-Travel by mile 448 31417.00000 13976.9300 0.4449
Subtotal (Total Children Is Unduplicated) 928 35043.00000 163119.4900 4.6548
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Total 39810.750000 384119.7200 9.6486
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Number of Children (Unduplicated) With at Least One Service 1499
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Center 03
Flag Claims Units Chgs Paid
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R 68 37.000000 1369.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1864 1806.000000 91634.4000 0.0000
P 1701 14620.250000 44198.0900 44198.0900
D 2 2.000000 100.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 54 452.250000 2245.3500 2245.3500
T 0 0.000000 0.0000 0.0000
6714 21853.000000 201351.3500 0.0000
Other 1498 1040.250000 43221.5300 0.0000
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Total 11901 39810.750000 384119.7200 46443.4400