CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 439 252.750000 9351.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1286 6481.000000 239279.0000 36.9201
Subtotal (Total Children Is Unduplicated) 1325 6733.750000 248630.7500 36.9231
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.0800 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
EXIT-EXIT-EXIT ASSESSMENT 4 4.000000 200.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 12 20.000000 1500.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 7 11.500000 862.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 7 11.500000 812.5000 70.6522
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 8 12.500000 908.2500 72.6600
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 18 31.500000 1698.2500 53.9127
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 173 283.500000 20821.6700 73.4450
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 36 62.500000 4460.0000 71.3600
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 40 62.500000 4687.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 210 347.500000 18858.2500 54.2683
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 60.000000 4485.0000 74.7500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 28 29.000000 1480.4500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 40 41.000000 2093.0500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 329 998.000000 63882.5300 64.0106
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 3.500000 175.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 71 77.000000 3850.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 69 72.000000 3600.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 11 11.000000 550.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 48 48.000000 2400.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 132 135.000000 6750.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 10 253.000000 6325.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1005 8553.500000 427675.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 86 482.000000 24100.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1012 9028.000000 90280.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 26 119.250000 8519.2200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 5 17.500000 1250.2000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 44 143.000001 8179.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 8 13.000000 928.7200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 5 14.000035 1000.1600 71.4398
PHY-97110HM-PT SESSION BY PT ASST 33 197.000000 11260.5200 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 5.000000 285.8000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 45 210.250015 15020.2600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 14.500000 1035.8800 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 32 112.000000 6406.4000 57.2000
TRAV-TRAVS-Travel by mile 17 3014.000000 1341.1900 0.4450
Subtotal (Total Children Is Unduplicated) 1108 22525.50005 621057.9500 27.5713
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Total 30257.250051 933571.2300 30.8545
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Number of Children (Unduplicated) With at Least One Service 1505
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Center 57
Flag Claims Units Chgs Paid
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R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 725 955.500000 40454.7500 0.0000
P 2083 2779.890472 114432.6800 114782.3700
D 0 0.000000 0.0000 0.0000
S 21 24.500000 1120.3500 1007.8500
H 0 0.000000 0.0000 0.0000
T 4177 16002.109579 293296.5700 289575.1000
4365 10435.000000 482806.5900 335984.1500
Other 35 59.750000 1441.7900 1377.0400
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Total 11407 30257.250051 933571.2300 742726.5100