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: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 483 276.500000 10230.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1430 7470.500000 275761.0000 36.9133
Subtotal (Total Children Is Unduplicated) 1472 7747.000000 285991.5000 36.9164
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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 14 23.000000 1725.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 8 13.500000 1012.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 8 13.000000 925.0000 71.1538
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 9 14.000000 1020.7500 72.9107
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 21 36.500000 1975.7500 54.1301
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 237 382.000000 28010.9200 73.3270
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 54 89.000000 6397.5000 71.8820
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 63 92.000000 6800.0000 73.9130
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 302 485.000000 26312.0300 54.2516
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 53 81.000000 5980.7500 73.8364
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 41 42.000000 2144.1000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 443 1333.500000 85608.1100 64.1981
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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 1006 8573.500000 428675.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 86 482.000000 24100.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1014 9054.000000 90540.0000 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 46 215.250015 15377.4600 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) 1110 22576.50005 622675.1500 27.5807
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Total 31657.000051 994274.7600 31.4077
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Number of Children (Unduplicated) With at Least One Service 1652
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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 780 1051.750000 45074.2500 0.0000
P 2316 3232.890472 134625.9300 135138.5800
D 2 2.000000 130.5000 0.0000
S 21 24.500000 1120.3500 1007.8500
H 0 0.000000 0.0000 0.0000
T 4208 16086.359579 296367.6000 291502.3500
4822 11191.000000 515190.5900 335984.1500
Other 39 68.000000 1747.0400 1377.0400
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Total 12189 31657.000051 994274.7600 765009.9700