CMS/EIP Fiscal Report Center: 57
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 482 276.250000 10221.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 602 3782.250000 139943.2500 37.0000
Subtotal (Total Children Is Unduplicated) 907 4058.500000 150164.5000 37.0000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 4 4.000000 200.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 27 46.500000 3487.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 8.500000 637.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 8.500000 637.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 32 56.000000 3108.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.500000 487.5000 75.0000
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 14 14.000000 714.7000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 18 18.000000 918.9000 51.0500
Subtotal (Total Children Is Unduplicated) 71 184.000000 11609.3000 63.0940
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 3.500000 175.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 71 76.000000 3800.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 69 72.000000 3600.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 11 11.000000 550.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 48 48.000000 2400.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 130 133.000000 6650.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 309 1348.500000 67425.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 22 65.000000 3250.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1011 9016.000000 90160.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 6.000000 428.6400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 1 6.000000 428.6400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 6 29.000000 1658.8000 57.2000
PHY-97110GT-PT SESSION BY LICENSED PT 1 2.500000 178.6000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 8 42.000000 2400.7200 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 3.000000 171.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 42.000000 3000.4800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 6.000000 428.6400 71.4400
TRAV-TRAVS-Travel by mile 17 3014.000000 1341.1900 0.4450
Subtotal (Total Children Is Unduplicated) 1034 13925.50000 188122.1900 13.5092
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Total 18168.000000 349895.9900 19.2589
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Number of Children (Unduplicated) With at Least One Service 1465
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Center 57
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 15 18.000000 752.6000 752.6000
H 0 0.000000 0.0000 0.0000
T 3548 13940.500000 189097.3900 189069.3900
2720 4206.500000 159936.0000 0.0000
Other 3 3.000000 110.0000 110.0000
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Total 6286 18168.000000 349895.9900 189931.9900