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
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 402 189.500000 7002.2500 36.9512
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 64 28.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 838 2683.750000 99095.2500 36.9242
Subtotal (Total Children Is Unduplicated) 924 2901.500000 106097.5000 36.5664
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 12.000000 900.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 12.000000 666.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 197 415.000000 29332.5000 70.6807
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 25 50.000000 3750.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 61 128.000000 9135.0000 71.3672
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 36 74.000000 5400.0000 72.9730
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 29 62.000000 4480.0000 72.2581
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 212 427.500000 23483.2500 54.9316
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 21 41.500000 2303.2500 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 42 43.000000 2100.0000 48.8372
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 357.3500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 304 1311.000000 84280.4500 64.2871
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 58 63.750000 3187.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 77 86.000000 4281.2500 49.7820
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 27 22.000000 550.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 84 115.750000 5787.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 14 11.250000 562.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 1.250000 31.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 53 71.750000 3587.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 8 5.750000 287.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 2.250000 56.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 25 28.000000 1400.0000 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 54 58.250000 2912.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 7 4.750000 237.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 2.000000 50.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 147 228.750000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 433 2241.000000 111825.0000 49.8996
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 21 37.500000 1875.0000 50.0000
INTR-T1013-INTERPRETER 5 12.000000 600.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 632 4160.000000 41590.0000 9.9976
OCCT-97530-OT SESSION BY LICENSED OT 22 86.000000 5652.3200 65.7247
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 148 935.500000 60937.5900 65.1391
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 13 45.000000 3214.8000 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 116 636.000000 45435.8400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 10 21.000000 1500.2400 71.4400
TRAV-TRAVS-Travel by mile 517 42415.00000 18864.7700 0.4448
Subtotal (Total Children Is Unduplicated) 785 51866.50000 352747.1900 6.8011
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Total 56079.000000 543125.1400 9.6850
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Number of Children (Unduplicated) With at Least One Service 1012
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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 628 657.500000 29680.9700 252.1000
P 1999 2247.500000 107103.7500 109517.7700
D 215 243.750000 12506.2500 130.0000
S 21 27.250000 1386.3200 231.7500
H 179 241.000000 15506.3200 35.0000
T 4945 48326.250000 163240.7300 156618.6400
3804 4324.000000 213266.0500 86.6000
Other 19 11.750000 434.7500 0.0000
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Total 11810 56079.000000 543125.1400 266871.8600