CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2021 ending 09/30/2021 Date of Report:10/13/2021 Page: 1
List order: No List
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 1028 1580.250000 58349.0000 36.9239
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 29 39.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1195 3301.750000 122127.7500 36.9888
Subtotal (Total Children Is Unduplicated) 1355 4921.250000 180476.7500 36.6729
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 7 13.500000 1012.5000 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 6 10.500000 787.5000 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 5 10.000000 750.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 10 19.000000 1054.5000 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 123 229.500000 17212.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 13.000000 975.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 111 208.500000 15637.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 34 60.000000 4500.0000 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 131 242.500000 13458.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 68.000000 5100.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 2.000000 102.1000 51.0500
SPCH-92522GT-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 288 899.500000 62055.8300 68.9893
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 342.0000 342.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 2.750000 137.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 26 19.500000 975.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 0.750000 18.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 3 1.500000 75.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 148 116.000000 5800.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 18 14.750000 737.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 187 137.000000 6850.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 7 4.500000 112.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 8 6.250000 312.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 121 59.750000 2987.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 16 12.750000 637.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 149 97.750000 4887.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 99 201.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 1.250000 31.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 41 82.250000 4112.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 378 1663.500000 83162.0000 49.9922
INTR-T1013-INTERPRETER 1 4.000000 300.0000 75.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 142 354.000000 3490.0000 9.8588
OCCT-97530-OT SESSION BY LICENSED OT 35 72.500000 5179.4000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 45 146.250000 10448.1000 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 7 13.750000 982.3000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 51 123.000000 8787.1200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 19 38.750000 2768.3000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 18 64.250000 4590.0200 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 6 14.000000 1000.1600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 26 83.500000 5965.2400 71.4400
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 25 55.000000 3929.2000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 47 198.000000 14198.7000 71.7106
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 19 57.500000 4107.8000 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 69 307.000000 21932.0800 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 78 66.250000 2451.2500 37.0000
TRAV-TRAVS-Travel by mile 30 1497.000000 666.0800 0.4449
Subtotal (Total Children Is Unduplicated) 697 5519.000000 202017.7500 36.6041
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Total 11339.750000 444550.3300 39.2028
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Number of Children (Unduplicated) With at Least One Service 1456
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Center 53
Flag Claims Units Chgs Paid
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R 31 31.000000 1550.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2434 2211.250000 106224.9400 74.0000
P 1776 1598.750000 76567.9100 76192.2100
D 73 74.250000 4923.6700 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 69 107.000000 3738.9100 3738.9100
8059 7231.250000 246372.9100 0.0000
Other 92 86.250000 5171.9900 0.0000
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Total 12534 11339.750000 444550.3300 80005.1200