CMS/EIP Fiscal Report Center: 07
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 1758 2080.000000 76904.5000 36.9733
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 85 101.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1727 3864.500000 142884.7500 36.9737
Subtotal (Total Children Is Unduplicated) 2092 6045.500000 219789.2500 36.3558
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 29.1600 14.5800
EXIT-EXIT-EXIT ASSESSMENT 40 59.250000 2962.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 13 28.000000 1554.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 61 122.000000 9062.5000 74.2828
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 42 84.000000 6300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 324.8800 40.6100
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 41.500000 3112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 135 270.000000 14985.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 83 166.000000 9213.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 81 168.500000 12637.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 59 120.000000 8950.0000 74.5833
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 3.000000 153.1500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 18 18.000000 878.6500 48.8139
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 397 1129.250000 72746.3900 64.4201
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 57 55.500000 2775.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 106 117.000000 5850.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 17 15.500000 387.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 226 346.500000 17325.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 138 233.500000 11675.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 3 2.500000 62.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 128 173.500000 8675.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 66 81.500000 4075.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 35 60.000000 3000.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 35 51.750000 2587.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 118 156.250000 7812.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 96 116.250000 5812.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 3 2.500000 62.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 51 100.750000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 382 2067.750000 103199.5000 49.9091
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 62 179.500000 8975.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1358 9466.000000 94945.0000 10.0301
OCCT-97530-OT SESSION BY LICENSED OT 23 118.750000 8363.5000 70.4295
OCCT-97530GT-OT SESSION BY LICENSED OT 3 3.000000 214.3200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 24 121.000000 7727.9000 63.8669
PHY-97110GT-PT SESSION BY LICENSED PT 3 6.750000 414.0000 61.3333
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 99 557.250000 35986.9200 64.5795
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 9 16.250000 1160.9000 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 1 1.000000 37.0000 37.0000
TRAV-TRAVS-Travel by mile 31 1428.000000 635.1900 0.4448
Subtotal (Total Children Is Unduplicated) 1443 15478.25000 331759.2300 21.4339
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Total 22653.000000 624294.8700 27.5590
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Number of Children (Unduplicated) With at Least One Service 2379
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Center 07
Flag Claims Units Chgs Paid
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R 12 11.500000 538.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 399 336.250000 13382.2500 0.0000
P 8825 17948.374000 445615.4200 445214.5300
D 24 26.750000 1406.7500 0.0000
S 4 6.500000 468.5000 0.0000
H 6 12.000000 900.0000 0.0000
T 0 0.000000 0.0000 0.0000
7187 4112.626000 154329.7000 290.0000
Other 329 199.000000 7653.7500 0.0000
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Total 16786 22653.000000 624294.8700 445504.5300