CMS/EIP Fiscal Report Center: 06
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 1146 681.500000 25197.2500 36.9732
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5 4.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 882 2188.000000 80956.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1603 2873.500000 106153.2500 36.9421
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 8 16.000000 800.0000 50.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 21 32.000000 2400.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 -112.5000 0.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 4.000000 300.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 10 15.500000 1162.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 -83.2500 0.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 14 21.500000 1193.2500 55.5000
Subtotal (Total Children Is Unduplicated) 32 92.000000 5660.0000 61.5217
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 55 51.000000 2425.0000 47.5490
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 16 15.500000 775.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 58 46.000000 1150.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 6 6.250000 287.5000 46.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 3 5.500000 275.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 17 15.750000 381.2500 24.2063
CONOF-CONOF-CONSULT, OT, FACE TO FACE 5 6.750000 337.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 3 5.500000 275.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 5 2.750000 68.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.500000 25.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 0.500000 25.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 1 1.000000 50.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 14 13.500000 325.0000 24.0741
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 312 2254.500000 112625.0000 49.9556
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 71 245.250000 12162.5000 49.5923
INTR-T1013-INTERPRETER 8 70.000000 5600.0000 80.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1159 8591.000000 85730.0000 9.9790
OCCT-97530-OT SESSION BY LICENSED OT 4 8.500000 597.9300 70.3447
OCCT-97530HM-OT SESSION BY OT ASST 1 2.500000 143.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 5 12.500000 893.0000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 0.500000 35.7200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 2.500000 142.9000 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 1.000000 57.1600 57.1600
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 23.750000 1696.7000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 8.000000 571.5200 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 1 0.500000 18.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1202 11395.00000 226816.9300 19.9050
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Total 14360.500000 338630.1800 23.5807
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Number of Children (Unduplicated) With at Least One Service 2147
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Center 06
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 7723 7673.750000 147479.5200 147479.5200
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
8524 6513.500000 184740.4100 0.0000
Other 230 173.250000 6410.2500 0.0000
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Total 16477 14360.500000 338630.1800 147479.5200