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
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 477 210.000000 7770.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 47 27.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 473 1157.250000 42818.2500 37.0000
Subtotal (Total Children Is Unduplicated) 769 1394.750000 50588.2500 36.2705
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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 3 5.000000 375.0000 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 3 5.000000 277.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 27.000000 2025.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 32 51.500000 3862.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 21 37.500000 2812.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 15.500000 1162.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 29 47.000000 3525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 37 63.000000 3496.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 32 52.500000 2913.7500 55.5000
OCTH-97167-OT EVAL HIGH COMPLEXITY 6 6.000000 271.3500 45.2250
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 164.2000 41.0500
Subtotal (Total Children Is Unduplicated) 119 334.500000 22160.0500 66.2483
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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 80 64.250000 3212.5000 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 17 14.750000 737.5000 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 47 32.500000 1625.0000 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 172 1000.250000 50012.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 8 22.250000 1112.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 632 4327.000000 43270.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 24 105.250000 6583.9800 62.5556
PHY-97110-PT SESSION BY LICENSED PT 5 12.000000 547.8100 45.6508
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 19 53.500000 2648.6900 49.5082
TRAV-TRAVS-Travel by mile 321 20644.00000 9180.9200 0.4447
Subtotal (Total Children Is Unduplicated) 657 26485.75000 129125.1500 4.8753
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Total 28215.000000 201873.4500 7.1548
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Number of Children (Unduplicated) With at Least One Service 1056
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Center 05
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 4513 25885.500000 148730.0600 148730.0600
D 0 0.000000 0.0000 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
2504 2329.500000 53143.3900 2555.1400
Other 0 0.000000 0.0000 0.0000
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Total 7017 28215.000000 201873.4500 151285.2000