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
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 1968 6388.500000 236292.5000 36.9872
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 2.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 772 2977.250000 110093.5000 36.9783
Subtotal (Total Children Is Unduplicated) 2031 9368.000000 346386.0000 36.9754
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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 131 214.000000 10700.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 67 130.500000 9787.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 37 72.500000 5437.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 64 121.000000 9075.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 77 148.500000 8241.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 17.500000 1312.5000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 4.000000 200.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 2 5.000000 250.0000 50.0000
Subtotal (Total Children Is Unduplicated) 298 741.500000 47035.7500 63.4332
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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 78 128.750000 6437.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 51 99.000000 4950.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 91 112.500000 2812.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 11 13.000000 650.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 7 11.000000 550.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 20 25.000000 1250.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 5 4.000000 200.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 0.500000 25.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 12 12.000000 600.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 6 7.000000 350.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 319 1960.500000 95015.1700 48.4648
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 36 146.000000 7300.0000 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 83 497.500000 35541.4000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 3 15.750000 1125.1800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 67 433.250000 30379.8600 70.1209
PHY-97110GT-PT SESSION BY LICENSED PT 8 38.000000 2714.7200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 199 1422.000000 97398.8000 68.4942
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 30.250000 2161.0600 71.4400
TRAV-TRAVS-Travel by mile 912 87495.00000 37966.5100 0.4339
Subtotal (Total Children Is Unduplicated) 1180 93098.00000 352764.7000 3.7892
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Total 103207.500000 746186.4500 7.2300
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Number of Children (Unduplicated) With at Least One Service 2141
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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 0 0.000000 0.0000 0.0000
P 14615 96876.750000 722696.6000 722696.6000
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 261 6308.750000 21817.8500 21817.8500
0 0.000000 0.0000 0.0000
Other 12 22.000000 1672.0000 0.0000
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Total 14888 103207.500000 746186.4500 744514.4500