CMS/EIP Fiscal Report Center: 53
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 1025 1584.000000 58608.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 17 14.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1154 2803.250000 103674.0000 36.9835
Subtotal (Total Children Is Unduplicated) 1346 4401.250000 162282.0000 36.8718
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 13.8700 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.0800 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 55.6600 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 4 8.000000 400.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 14.500000 1087.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 9 15.500000 1162.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 18 37.000000 2053.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 83 140.000000 10500.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 8.500000 637.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 76 129.500000 9712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 43 65.000000 4875.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 172 302.500000 16788.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 73.000000 5475.0000 75.0000
Subtotal (Total Children Is Unduplicated) 264 824.500000 54544.0600 66.1541
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 482.2300 241.1150
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 6 5.000000 250.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 17 13.250000 662.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 2.500000 62.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 15 11.250000 562.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 142 131.000000 6550.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 17 5.750000 143.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 10 9.750000 487.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 100 75.500000 3775.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 11 4.750000 118.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 30 42.000000 2100.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 147 78.750000 3937.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 8 2.000000 50.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 19 12.750000 637.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 137 73.000000 3650.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 4 4.500000 112.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 163 505.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 102 328.750000 16437.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 420 1818.000000 90900.0000 50.0000
INTR-T1013-INTERPRETER 1 4.000000 300.0000 75.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 185 602.000000 6020.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 27 64.000000 4572.1600 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 32 112.750000 8054.8600 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 12 16.000000 1143.0400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 46 149.250000 10662.4200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 12 69.250000 4947.2200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 14 36.000000 2571.8400 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 25 81.500000 5822.3600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 19 47.000000 3357.6800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 33 97.500000 6965.4000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 37 172.000000 12347.2400 71.7863
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 21 82.000000 5858.0800 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 60 257.500000 18338.2400 71.2165
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.8800 13.8800
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 62 60.000000 2220.0000 37.0000
TRAV-TRAVS-Travel by mile 36 1604.000000 713.5300 0.4448
Subtotal (Total Children Is Unduplicated) 729 6581.500000 224827.6800 34.1606
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Total 11807.250000 441653.7400 37.4053
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Number of Children (Unduplicated) With at Least One Service 1430
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Center 53
Flag Claims Units Chgs Paid
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R 34 31.750000 1588.0300 0.0000
U 0 0.000000 0.0000 0.0000
B 2051 1892.500000 93358.4400 1055.0000
P 1440 1401.500000 66480.6400 66462.1400
D 61 64.250000 4090.2200 0.0000
S 178 146.750000 8505.0600 1665.0000
H 0 0.000000 0.0000 0.0000
T 103 104.500000 5130.5600 5130.5600
8971 7955.750000 250599.2300 0.0000
Other 249 210.250000 11901.5600 0.0000
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Total 13087 11807.250000 441653.7400 74312.7000