CMS/EIP Fiscal Report Center: 55
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 1071 1127.750000 41726.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 60 45.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 456 1142.250000 42263.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1156 2315.750000 83990.0000 36.2690
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 8 14.000000 700.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 2 4.000000 200.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 36 62.000000 3100.0000 50.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.766267 132.4700 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 16 31.800000 2385.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 11.800000 885.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 24 48.000000 2664.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 1.804113 92.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 1.142801 58.3400 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 98 208.313181 12287.1100 58.9838
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 3.000000 465.7000 155.2333
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 3.000000 150.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 35 27.750000 1387.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 9 9.000000 450.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 48 74.500000 1862.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 18 31.000000 1550.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 35 77.000000 1925.0000 25.0000
CONPP-CONPP-CONSULT, PT, PHONE 3 4.000000 100.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 31 23.750000 1187.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 9 9.000000 450.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 41 51.500000 1287.5000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 14.250000 356.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 107 676.500000 33825.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 14 60.000000 3000.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 682 6222.000000 62220.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 20 83.788910 5985.8800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 1 0.050112 3.5800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 9 48.584963 2779.0600 57.2000
PHY-97110-PT SESSION BY LICENSED PT 4 4.360018 311.4800 71.4401
PHY-97110HM-PT SESSION BY PT ASST 6 26.210464 1498.1900 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 3.250000 185.7700 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 41 182.673161 13050.1700 71.4400
TRAV-TRAVS-Travel by mile 81 4416.000000 1964.5200 0.4449
Subtotal (Total Children Is Unduplicated) 714 12051.16763 135995.6000 11.2848
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Total 14575.230809 232272.7100 15.9361
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Number of Children (Unduplicated) With at Least One Service 1276
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Center 55
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 6914 10057.115218 117864.0600 117864.0600
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 0 0.000000 0.0000 0.0000
5453 4518.115591 114408.6500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 12367 14575.230809 232272.7100 117864.0600