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
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 1025 1584.000000 58608.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 17 14.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 365 760.500000 28138.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1131 2358.500000 86746.5000 36.7804
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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-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 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 13.500000 1012.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 11 19.000000 1425.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 7.000000 525.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 19 33.500000 1859.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
Subtotal (Total Children Is Unduplicated) 40 98.500000 6178.0600 62.7214
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EI Services,Class #03
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 5 22.000000 1100.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 26 118.750000 5937.5000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 150.0000 75.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 185 602.000000 6020.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 25.000000 1786.0000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 10 22.000000 1571.6800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 7.000000 500.0800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 3.750000 267.9000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 11.000000 785.8400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 22.000000 1571.6800 71.4400
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) 424 3476.500000 45724.2100 13.1524
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Total 5933.500000 138648.7700 23.3671
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Number of Children (Unduplicated) With at Least One Service 1205
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Center 53
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 0 0.000000 0.0000 0.0000
D 15 18.000000 779.0000 0.0000
S 18 13.750000 618.9400 92.5000
H 0 0.000000 0.0000 0.0000
T 70 70.500000 3395.3100 3395.3100
6885 5812.500000 133161.7700 0.0000
Other 25 18.750000 693.7500 0.0000
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Total 7013 5933.500000 138648.7700 3487.8100