CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 428 188.500000 6974.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 38 20.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1027 2480.500000 91778.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1041 2689.500000 98753.0000 36.7180
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 13.500000 749.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 19 32.500000 2437.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 27.500000 2062.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 11.500000 862.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 20 35.000000 2625.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 17 30.500000 1692.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 19 32.000000 1776.0000 55.5000
OCTH-97167-OT EVAL HIGH COMPLEXITY 8 8.000000 373.4500 46.6813
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 5 5.000000 215.2500 43.0500
Subtotal (Total Children Is Unduplicated) 82 219.500000 14507.3000 66.0925
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 81 104.000000 5200.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 13 9.500000 475.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 3.000000 75.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 79 63.750000 3187.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 4 2.500000 125.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 7 4.000000 100.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 55 63.500000 3175.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 3 3.500000 175.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 1.500000 37.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 16 13.750000 687.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 8 4.000000 200.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 4 2.750000 68.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 46 31.000000 1550.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 15 10.750000 537.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 174 1023.500000 51175.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 9 26.250000 1312.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 605 4275.000000 42750.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 28 136.250000 8264.2000 60.6547
PHY-97110-PT SESSION BY LICENSED PT 22 78.250000 4076.9600 52.1017
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 46 181.000000 9566.1200 52.8515
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.750000 196.4600 71.4400
TRAV-TRAVS-Travel by mile 310 20426.00000 9083.9600 0.4447
Subtotal (Total Children Is Unduplicated) 632 26468.50000 142115.3900 5.3692
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Total 29377.500000 255375.6900 8.6929
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Number of Children (Unduplicated) With at Least One Service 1112
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Center 05
Flag Claims Units Chgs Paid
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R 11 9.000000 333.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2348 1541.000000 57017.0000 24341.3800
P 4494 25775.250000 152033.0300 152033.0300
D 1 0.500000 18.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2165 2028.750000 45123.1600 4589.6600
Other 30 23.000000 851.0000 0.0000
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Total 9049 29377.500000 255375.6900 180964.0700