CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 183 387.250000 14328.2500 37.0000
Subtotal (Total Children Is Unduplicated) 183 387.250000 14328.2500 37.0000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 2 4.000000 200.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 4.000000 222.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 61 95.500000 7162.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 62 98.500000 7387.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 90 143.000000 7936.5000 55.5000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 115 356.000000 23625.0000 66.3624
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 9 12.250000 612.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 21 36.000000 1800.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 31 34.000000 850.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 4.000000 200.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 5 6.000000 150.0000 25.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 10 15.000000 750.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 180 959.000000 46909.0800 48.9146
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 14 37.000000 1850.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 36 151.000000 10787.4400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 54 324.000000 23146.5600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 12 67.000000 4786.4800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 105 768.500000 54901.6400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 14 82.000000 5858.0800 71.4400
TRAV-TRAVS-Travel by mile 552 43696.00000 19279.2500 0.4412
Subtotal (Total Children Is Unduplicated) 651 46196.75000 172152.4700 3.7265
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Total 46940.000000 210105.7200 4.4760
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Number of Children (Unduplicated) With at Least One Service 823
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Center 09
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 1947 46204.750000 172602.4700 172602.4700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 333 525.000000 29724.0000 0.0000
T 0 0.000000 0.0000 0.0000
241 210.250000 7779.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2521 46940.000000 210105.7200 172602.4700