CMS/EIP Fiscal Report Center: 07
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 1758 2080.000000 76904.5000 36.9733
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 85 101.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 620 1467.750000 54279.0000 36.9811
Subtotal (Total Children Is Unduplicated) 1886 3648.750000 131183.5000 35.9530
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 40 59.250000 2962.5000 50.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 11.298600 759.8950 67.2557
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 6.996500 524.7375 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 24.8800 6.2200
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 72 144.000000 7992.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 42 84.000000 4662.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 47.330900 3549.8175 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 20.000000 1450.0000 72.5000
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 215.0000 43.0000
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 180 393.876000 22797.9300 57.8810
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 57 55.500000 2775.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 106 117.000000 5850.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 17 15.500000 387.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 226 346.500000 17325.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 138 233.500000 11675.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 3 2.500000 62.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 128 173.500000 8675.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 66 81.500000 4075.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 35 60.000000 3000.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 35 51.750000 2587.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 118 156.250000 7812.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 96 116.250000 5812.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 3 2.500000 62.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 51 100.750000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 350 1863.250000 92974.5000 49.8991
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 55 151.000000 7550.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1358 9466.000000 94945.0000 10.0301
OCCT-97530-OT SESSION BY LICENSED OT 3 10.000000 624.4000 62.4400
PHY-97110-PT SESSION BY LICENSED PT 8 36.500000 1700.3300 46.5844
PHY-97110GT-PT SESSION BY LICENSED PT 1 4.000000 217.5400 54.3850
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 35 175.000000 8976.5300 51.2945
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 10.250000 732.2600 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 1 1.000000 37.0000 37.0000
TRAV-TRAVS-Travel by mile 31 1428.000000 635.1900 0.4448
Subtotal (Total Children Is Unduplicated) 1440 14658.00000 278492.7500 18.9994
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Total 18700.626000 432474.1800 23.1262
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Number of Children (Unduplicated) With at Least One Service 2315
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Center 07
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 5695 14677.000000 285246.7300 285256.7300
D 18 16.250000 677.2500 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
7119 3999.626000 146272.7000 290.0000
Other 9 7.750000 277.5000 0.0000
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Total 12841 18700.626000 432474.1800 285546.7300