CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Agency Filter:EXT
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.250000 9.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 0.250000 9.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1 0.500000 18.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 38 68.000000 4950.0000 72.7941
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 6.500000 487.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 23 46.000000 3450.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 49 98.000000 5439.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 6 12.000000 666.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97165TLGT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97161TL-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 18 19.000000 900.0000 47.3684
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 106 290.500000 18290.7500 62.9630
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 32 34.000000 1700.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 61 65.500000 3256.2500 49.7137
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 16 13.500000 337.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 48 66.000000 3300.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 11 8.000000 400.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.500000 12.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 44 61.750000 3087.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 6 3.750000 187.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 2.250000 56.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 23 26.000000 1300.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 5 4.250000 193.7500 45.5882
CONPP-CONPP-CONSULT, PT, PHONE 6 3.500000 87.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 23 24.000000 1200.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 6 4.000000 200.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.500000 37.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 268 1319.500000 65775.0000 49.8484
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 18 33.000000 1650.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 532 3379.000000 33780.0000 9.9970
OCCT-97530-OT SESSION BY LICENSED OT 21 82.000000 5572.3200 67.9551
OCCT-97530GT-OT SESSION BY LICENSED OT 5 13.000000 857.2800 65.9446
OCCT-97530HM-OT SESSION BY OT ASST 11 43.000000 2288.0000 53.2093
OCCT-97530TL-OT SESSION BY LICENSED OT 27 145.000000 10358.8000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLHM-OT SESSION BY OT ASST 12 51.750000 2960.1000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 23 148.250000 9751.5600 65.7778
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.500000 178.6000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 4 8.000000 457.2800 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 28 145.750000 10412.3800 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 2 9.250000 660.8200 71.4400
PHY-97110TLHM-PT SESSION BY PT ASST 1 0.750000 42.8700 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 114 720.750000 48295.9600 67.0079
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 8 23.750000 1696.7000 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 92 532.250000 38023.9400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 9 20.000000 1428.8000 71.4400
TRAV-TRAVS-Travel by mile 337 26728.00000 11884.8800 0.4447
Subtotal (Total Children Is Unduplicated) 562 33725.00000 261502.9800 7.7540
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Total 34016.000000 279812.2300 8.2259
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Number of Children (Unduplicated) With at Least One Service 586
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Center 52
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 1 1.000000 50.0000 50.0000
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 3582 31330.750000 119458.1900 119458.1900
1396 2684.250000 160304.0400 32.9900
Other 0 0.000000 0.0000 0.0000
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Total 4979 34016.000000 279812.2300 119541.1800