CMS/EIP Fiscal Report Center: 54
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 825 686.250000 25382.0000 36.9865
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 49 42.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 701 1894.250000 70087.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1185 2623.250000 95469.2500 36.3935
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 7 7.000000 339.5000 48.5000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 16 29.000000 2175.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 16 30.000000 2250.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 15 29.500000 2212.5000 75.0000
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 33 63.500000 3524.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 48.000000 3600.0000 75.0000
Subtotal (Total Children Is Unduplicated) 72 219.000000 14845.2500 67.7865
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 10 22.000000 1040.0500 47.2750
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 52 45.000000 2250.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 154 172.750000 8637.5000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 41 26.250000 1300.0000 49.5238
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 273 191.500000 9575.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 10 9.000000 450.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 287 154.750000 7737.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 0.750000 18.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 19 14.750000 737.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 272 138.250000 6912.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 7 5.000000 250.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 288 155.250000 7762.5000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 127 274.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 14 27.500000 1375.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 64 324.250000 16212.5000 50.0000
INTR-T1013-INTERPRETER 8 42.750000 1693.7500 39.6199
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 167 473.000000 4730.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 7.500000 535.8000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 9 18.000000 1285.9200 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 8 18.000000 1285.9200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 12 34.000000 2428.9600 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 4 7.750000 553.6600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 41.000000 2929.0400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 22 96.750000 6911.8200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 357.2000 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 76 97.500000 3607.5000 37.0000
TRAV-TRAVS-Travel by mile 52 3967.000000 1765.1200 0.4450
Subtotal (Total Children Is Unduplicated) 630 6372.500000 92557.8100 14.5246
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Total 9214.750000 202872.3100 22.0160
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Number of Children (Unduplicated) With at Least One Service 1307
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Center 54
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 1 1.750000 64.7500 64.7500
D 18 17.750000 1225.1800 0.0000
S 14 9.500000 325.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 460 2048.250000 17631.4500 17631.4500
7052 7087.750000 181784.9300 0.0000
Other 83 49.750000 1840.7500 0.0000
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Total 7628 9214.750000 202872.3100 17696.2000