CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:GR
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 1 0.250000 9.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 0.250000 9.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1 0.500000 18.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 3 5.000000 273.0500 54.6100
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 32 34.000000 1700.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 61 65.500000 3256.2500 49.7137
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 16 13.500000 337.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 48 65.000000 3250.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 11 8.000000 400.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.500000 12.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 42 60.250000 3012.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 6 3.750000 187.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 2.250000 56.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 23 26.000000 1300.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 4 3.500000 175.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 6 3.500000 87.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 23 24.000000 1200.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 6 4.000000 200.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.500000 37.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 30.250000 1512.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 531 3374.000000 33730.0000 9.9970
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 3.000000 171.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 11.000000 785.8400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 9.000000 642.9600 71.4400
TRAV-TRAVS-Travel by mile 337 26728.00000 11884.8800 0.4447
Subtotal (Total Children Is Unduplicated) 553 30472.50000 64083.0400 2.1030
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Total 30478.000000 64374.5900 2.1122
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Number of Children (Unduplicated) With at Least One Service 554
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Center 52
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 0 0.000000 0.0000 0.0000
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 3121 30445.500000 64341.8500 64341.8500
3 32.500000 32.7400 14.2400
Other 0 0.000000 0.0000 0.0000
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Total 3124 30478.000000 64374.5900 64356.0900