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
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 459 229.250000 8482.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 13 6.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 516 1265.750000 46832.7500 37.0000
Subtotal (Total Children Is Unduplicated) 826 1501.000000 55315.0000 36.8521
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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 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 48.000000 3600.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.500000 562.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 43.000000 3225.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 88 169.500000 9407.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 52.500000 3937.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.000000 525.0000 75.0000
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 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 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 150 364.750000 23432.1500 64.2417
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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 171 681.750000 34087.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 115 351.500000 17575.0000 50.0000
INTR-T1013-INTERPRETER 7 81.000000 3850.0000 47.5309
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 154 576.000000 5560.0000 9.6528
OCCT-97530-OT SESSION BY LICENSED OT 6 16.000000 1143.0400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 13 50.750000 3576.1100 70.4652
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 50.250000 3589.8600 71.4400
TRAV-TRAVS-Travel by mile 448 31417.00000 13976.9300 0.4449
Subtotal (Total Children Is Unduplicated) 835 34315.50000 115720.9400 3.3723
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Total 36181.250000 194468.0900 5.3748
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Number of Children (Unduplicated) With at Least One Service 1242
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Center 03
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 1664 14583.500000 42010.4600 42010.4600
D 0 0.000000 0.0000 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
6140 21139.000000 149761.1500 0.0000
Other 5 6.500000 451.1300 0.0000
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Total 7863 36181.250000 194468.0900 44255.8100