CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 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 1146 681.500000 25197.2500 36.9732
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5 4.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2147 5497.750000 203290.7500 36.9771
Subtotal (Total Children Is Unduplicated) 2223 6183.250000 228488.0000 36.9527
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 8 16.000000 800.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 13.500000 944.2500 69.9444
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 10 17.000000 861.0000 50.6471
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 20.000000 1500.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 392 648.500000 48456.3100 74.7206
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 8.500000 412.5000 48.5294
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 119 197.000000 14737.5000 74.8096
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 120 203.500000 15262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 26.000000 1276.5000 49.0962
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 368 620.500000 34392.0000 55.4263
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 539 1793.500000 120221.3100 67.0317
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 2 2.000000 100.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 55 51.000000 2425.0000 47.5490
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 16 15.500000 775.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 58 46.000000 1150.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 6 7.250000 337.5000 46.5517
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 3 5.500000 275.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 17 15.750000 381.2500 24.2063
CONOF-CONOF-CONSULT, OT, FACE TO FACE 5 6.750000 337.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 3 5.500000 275.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 5 2.750000 68.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.500000 25.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 0.500000 25.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 1 1.000000 50.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 14 13.500000 325.0000 24.0741
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1020 7201.250000 359962.5000 49.9861
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 205 704.000000 35100.0000 49.8580
INTR-T1013-INTERPRETER 8 70.000000 5600.0000 80.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1159 8591.000000 85730.0000 9.9790
OCCT-97530-OT SESSION BY LICENSED OT 29 133.250000 9342.5100 70.1126
OCCT-97530GT-OT SESSION BY LICENSED OT 12 24.000000 1613.8900 67.2454
OCCT-97530HM-OT SESSION BY OT ASST 20 99.000000 4570.1800 46.1634
OCCT-97530HMGT-OT SESSION BY OT ASST 5 15.000000 858.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 44 174.750000 12319.2100 70.4962
PHY-97110GT-PT SESSION BY LICENSED PT 13 34.000000 2428.9600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 18 58.500000 3343.8600 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 4 6.000000 342.9600 57.1600
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 119 492.250000 33946.4900 68.9619
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 53 193.750000 13781.5000 71.1303
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 1 0.500000 18.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1313 17973.75000 575601.5600 32.0246
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Total 25950.500000 924310.8700 35.6182
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Number of Children (Unduplicated) With at Least One Service 2419
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Center 06
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 8237 7996.000000 168202.9200 168202.9200
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
21103 17780.500000 749669.9500 0.0000
Other 231 174.000000 6438.0000 0.0000
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Total 29571 25950.500000 924310.8700 168202.9200