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
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 402 189.500000 7002.2500 36.9512
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 64 28.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 341 1053.750000 38887.0000 36.9034
Subtotal (Total Children Is Unduplicated) 650 1271.500000 45889.2500 36.0906
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 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) 5 17.500000 1146.5500 65.5171
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 58 63.750000 3187.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 77 86.000000 4281.2500 49.7820
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 27 22.000000 550.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 84 114.750000 5737.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 14 11.250000 562.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 1.250000 31.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 51 70.250000 3512.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 8 5.750000 287.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 2.250000 56.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 25 28.000000 1400.0000 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 54 58.250000 2912.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 7 4.750000 237.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 2.000000 50.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 147 228.750000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 11 59.250000 2962.5000 50.0000
INTR-T1013-INTERPRETER 5 12.000000 600.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 632 4155.000000 41540.0000 9.9976
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 5 21.000000 1500.2400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 9.000000 642.9600 71.4400
TRAV-TRAVS-Travel by mile 517 42415.00000 18864.7700 0.4448
Subtotal (Total Children Is Unduplicated) 777 47382.25000 89493.5800 1.8888
-----------------------------------------------------------------------------------------------------------------------
Total 48671.250000 136529.3800 2.8051
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 936
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 2 3.000000 161.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4200 47088.250000 88208.6400 86564.2400
2353 1579.000000 48122.7400 14.2400
Other 3 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 6558 48671.250000 136529.3800 86578.4800