CMS/EIP Fiscal Report Center: 57
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
CASE-CASE-NON-TCM CASE MANAGEMENT 530 317.000000 11729.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 643 3398.750000 125753.7500 37.0000
Subtotal (Total Children Is Unduplicated) 942 3715.750000 137482.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 20 33.500000 2512.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 9.500000 712.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 8.500000 637.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 28 50.500000 2802.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 7 7.000000 357.3500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 13 13.000000 663.6500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 52 140.000000 8781.7000 62.7264
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 53 53.000000 2650.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 70 70.000000 3500.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 30 30.000000 750.0000 25.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 9 9.000000 450.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 3 3.000000 75.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 44 44.000000 2200.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 109 109.000000 5450.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 14 14.000000 350.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 6.000000 300.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 326 2019.000000 100950.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 21 78.000000 3900.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 896 6108.000000 61080.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 15.250000 1089.4600 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 2 3.000000 214.3200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 9.000000 514.8000 57.2000
PHY-97110GT-PT SESSION BY LICENSED PT 1 6.000000 428.6400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 5 43.000000 2457.8800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 27.000000 1928.8800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 7.500000 535.8000 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 1.500000 85.8000 57.2000
TRAV-TRAVS-Travel by mile 13 2003.000000 891.3100 0.4450
Subtotal (Total Children Is Unduplicated) 922 10659.25000 189851.8900 17.8110
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Total 14515.000000 336116.3400 23.1565
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Number of Children (Unduplicated) With at Least One Service 1423
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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 11 11.000000 561.5500 561.5500
H 0 0.000000 0.0000 0.0000
T 2830 10673.750000 190582.8900 190582.8900
2916 3807.500000 144102.0500 85.8000
Other 27 22.750000 869.8500 102.1000
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Total 5784 14515.000000 336116.3400 191332.3400