CMS/EIP Fiscal Report Center: 09
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 1968 6388.500000 236292.5000 36.9872
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 2.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1956 7357.500000 272162.7500 36.9912
Subtotal (Total Children Is Unduplicated) 2176 13748.25000 508455.2500 36.9833
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Screening, Eval, and Assessment,Class #02
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
EXIT-EXIT-EXIT ASSESSMENT 133 218.000000 10900.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 14 26.000000 1950.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 7 13.500000 1012.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 8 15.500000 1162.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 25 46.500000 2530.7500 54.4247
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 282 513.000000 38190.0000 74.4444
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 188 341.000000 25370.6900 74.4009
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 128 236.500000 17737.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 419 766.000000 42048.0000 54.8930
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 19.500000 1462.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 53 101.500000 7612.5000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 6.000000 300.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 2 5.000000 250.0000 50.0000
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 44.5500 44.5500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 696 2339.500000 152443.3400 65.1607
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 3242.0000 1621.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 87 141.000000 7050.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 61 135.000000 6750.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 113 146.500000 3662.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 12 14.000000 700.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 8 12.000000 600.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 21 26.000000 1300.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 5 4.000000 200.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 6.000000 300.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 2 1.500000 75.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 5 6.000000 150.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 12 12.000000 600.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 16 22.000000 1100.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1055 8210.500000 406075.2500 49.4580
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 106 463.000000 23150.0000 50.0000
INTR-T1013-INTERPRETER 103 394.000000 19700.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 42 246.000000 2220.0000 9.0244
OCCT-97530-OT SESSION BY LICENSED OT 160 1146.500000 81219.7100 70.8414
OCCT-97530GT-OT SESSION BY LICENSED OT 8 27.750000 1982.4600 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 16.750000 1196.6200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 176 1430.500000 100982.6800 70.5926
PHY-97110GT-PT SESSION BY LICENSED PT 40 211.000000 15073.8400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 426 3592.750000 250949.2800 69.8488
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 35 195.250000 13748.6600 70.4157
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 9.000000 642.9600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 4 16.000000 1071.6400 66.9775
SPL-92508HA-GROUP SPL SESSION PER CHILD 1 8.000000 111.0400 13.8800
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.8800 13.8800
TRAV-TRAVS-Travel by mile 1185 131191.0000 57245.7600 0.4364
Subtotal (Total Children Is Unduplicated) 1563 147690.0000 1001188.2800 6.7790
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Total 163777.750000 1662086.8700 10.1484
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Number of Children (Unduplicated) With at Least One Service 2261
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Center 09
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 377 415.250000 16967.8200 166.5000
P 20816 148081.250000 1117264.4800 1117902.3320
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 333 525.000000 29724.0000 0.0000
T 298 6385.250000 26391.1500 26607.6500
2702 8095.750000 453184.9200 0.0000
Other 150 275.250000 18554.5000 0.0000
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Total 24676 163777.750000 1662086.8700 1144676.4820