CMS/EIP Fiscal Report Center: 54
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 825 686.250000 25382.0000 36.9865
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 49 42.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1517 5195.750000 192233.5000 36.9982
Subtotal (Total Children Is Unduplicated) 1560 5924.750000 217615.5000 36.7299
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 7 7.000000 339.5000 48.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 14.5800 14.5800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.7900 9.7900
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.7200 28.7200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 20.8900 20.8900
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 10 19.000000 1425.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 12 22.000000 1650.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 6 11.000000 825.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 9.000000 499.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 12 23.000000 1276.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 87 164.500000 12337.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 116 216.000000 16200.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 72 139.500000 10462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 173 325.500000 18065.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 13.500000 1012.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 102 201.000000 15075.0000 75.0000
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 311 1184.000000 81291.3300 68.6582
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 16 33.000000 1595.1900 48.3391
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 52 45.000000 2250.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 154 172.750000 8637.5000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 41 26.250000 1300.0000 49.5238
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 273 191.500000 9575.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 10 9.000000 450.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 287 154.750000 7737.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 0.750000 18.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 19 14.750000 737.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 272 138.250000 6912.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 7 5.000000 250.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 288 155.250000 7762.5000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 127 276.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 88 211.250000 10562.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 486 2422.500000 121125.0000 50.0000
INTR-T1013-INTERPRETER 8 42.750000 1693.7500 39.6199
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 167 473.000000 4730.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 26 75.500000 5393.7200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 60 197.000000 14109.4000 71.6213
OCCT-97530TL-OT SESSION BY LICENSED OT 10 23.500000 1678.8400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 49 147.500000 10537.4000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 22 51.000000 3643.4400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 41 149.250000 10662.4200 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 18 74.000000 5286.5600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 34 109.750000 7840.5400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 86.500000 6179.5600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 51 230.250000 16449.0600 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 9 19.000000 1357.3600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 41 197.250000 14091.5400 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 76 97.500000 3607.5000 37.0000
TRAV-TRAVS-Travel by mile 52 3967.000000 1765.1200 0.4450
Subtotal (Total Children Is Unduplicated) 850 9797.250000 287940.1500 29.3899
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Total 16906.000000 586846.9800 34.7123
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Number of Children (Unduplicated) With at Least One Service 1590
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Center 54
Flag Claims Units Chgs Paid
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R 3 4.250000 157.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3476 3012.750000 138675.9500 2109.2500
P 1754 1580.250000 73499.3100 73380.3400
D 33 33.500000 2185.9600 0.0000
S 24 18.000000 687.1900 0.0000
H 0 0.000000 0.0000 0.0000
T 584 2182.990000 24833.7200 24833.7200
9684 9877.010000 337264.6300 0.0000
Other 261 197.250000 9542.9700 0.0000
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Total 15819 16906.000000 586846.9800 100323.3100