CMS/EIP Fiscal Report Center: 55
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 1071 1128.500000 41754.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 60 45.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1152 3497.500000 129407.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1255 4671.750000 171162.0000 36.6377
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 8 14.000000 700.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 2 4.000000 200.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 45 74.000000 3700.0000 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 10 20.000000 1500.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 6 12.000000 900.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 9 20.000000 1110.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 235 472.000000 35400.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 55 110.000000 8250.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 84 172.000000 12900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 24.000000 1332.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 100 200.000000 11100.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 10.000000 750.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 22.000000 1650.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 17 16.999999 867.8500 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 4 4.000000 204.2000 51.0500
OCTF-97168TL-OT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 27 28.000000 1429.4000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 7 7.000000 357.3500 51.0500
PSTF-97164TL-PT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 7 10.897159 556.3000 51.0500
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 16 18.000000 918.9000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 428 1301.897158 87778.4500 67.4235
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 3.000000 465.7000 155.2333
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 3.000000 150.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 35 27.750000 1387.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 9 9.000000 450.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 48 74.500000 1862.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 18 31.000000 1550.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 35 77.000000 1925.0000 25.0000
CONPP-CONPP-CONSULT, PT, PHONE 3 4.000000 100.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 31 23.750000 1187.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 9 9.000000 450.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 41 51.500000 1287.5000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 18.000000 450.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 322 1965.500000 98275.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 33 133.500000 6675.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 682 6232.000000 62320.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 129 817.499992 58402.2000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 5 21.250000 1518.1000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 123 842.499997 48191.0000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 12 34.750000 1987.7000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 17 89.000000 6358.1600 71.4400
OCCT-97530TLGTHM-OT SESSION BY OT ASST 3 21.000000 1201.2000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 34 304.000000 17388.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 59 420.970045 30095.5400 71.4909
PHY-97110GT-PT SESSION BY LICENSED PT 1 9.000000 642.9600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 54 433.425645 24774.6100 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 5 8.814556 503.8400 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 5 24.250000 1732.4200 71.4400
PHY-97110TLHM-PT SESSION BY PT ASST 12 101.250000 5787.4500 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 230 1400.749994 100069.5800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 7 21.750000 1553.8200 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 62 404.000000 28861.7600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 3 18.000000 1285.9200 71.4400
CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 2
List order: No List
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SPL-92508HA-GROUP SPL SESSION PER CHILD 2 7.000000 97.1600 13.8800
TRAV-TRAVS-Travel by mile 81 4458.000000 1983.2000 0.4449
Subtotal (Total Children Is Unduplicated) 765 18099.71023 510971.1200 28.2309
-----------------------------------------------------------------------------------------------------------------------
Total 24073.357387 769911.5700 31.9819
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1329
-----------------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 150.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3206 2777.000000 118754.9600 0.0000
P 7682 10844.397693 170579.5700 170579.5700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 103 148.000000 10666.9800 0.0000
T 0 0.000000 0.0000 0.0000
11082 10301.959694 469760.0600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22074 24073.357387 769911.5700 170579.5700