CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 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
TCM-T1017TL-TARGETED CASE MANAGEMENT 113 70.250000 2599.2500 37.0000
Subtotal (Total Children Is Unduplicated) 113 70.250000 2599.2500 37.0000
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 3 3.000000 145.5000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 19 37.250000 1862.5000 50.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
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 13 21.500000 1612.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 4.000000 300.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 33 50.000000 2775.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 31.500000 2362.5000 75.0000
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 76 162.250000 10018.1000 61.7448
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 73 80.750000 4037.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 75 90.750000 4537.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 24 24.000000 600.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 51 66.750000 3337.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 60 92.500000 4575.0000 49.4595
CONIP-CONIP-CONSULT, ITDS PHONE 9 8.500000 212.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 25 29.500000 1475.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 19 23.500000 1175.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 2.000000 50.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 20 25.750000 1287.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 11 64.000000 750.0000 11.7188
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 44 51.000000 2550.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 40 64.750000 3237.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 10 10.000000 250.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 30 76.000000 3800.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 5 19.000000 950.0000 50.0000
INTR-T1013-INTERPRETER 83 205.750000 10249.0000 49.8129
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1240 7002.000000 70020.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 3.000000 214.3200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 2 6.000000 428.6400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 6 33.000000 2357.5200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 3.000000 214.3200 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 44.000000 3143.3600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 6.000000 428.6400 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 7 8.500000 314.5000 37.0000
TRAV-TRAVS-Travel by mile 381 24649.00000 10938.5900 0.4438
Subtotal (Total Children Is Unduplicated) 1395 32693.00000 131419.6500 4.0198
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Total 32925.500000 144037.0000 4.3746
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Number of Children (Unduplicated) With at Least One Service 1457
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Center 01
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 5463 15621.750000 74203.5600 74203.5600
D 925 4981.250000 10801.3700 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3342 12059.000000 45241.7500 45241.7500
308 263.500000 13790.3200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 10038 32925.500000 144037.0000 119445.3100