CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 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 902 484.500000 17926.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 2.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2003 5413.500000 200262.5000 36.9932
Subtotal (Total Children Is Unduplicated) 2055 5900.250000 218189.0000 36.9796
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 3 6.000000 300.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 8.500000 637.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 13.500000 1012.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 6 10.000000 750.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.500000 360.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 11.500000 638.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 74 134.500000 10087.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 290 488.500000 36229.0000 74.1638
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 43 74.500000 5587.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 186 306.500000 22958.2500 74.9046
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 39.500000 2962.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 91 149.000000 11175.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 63 112.500000 6243.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 256 445.000000 24475.5000 55.0011
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
Subtotal (Total Children Is Unduplicated) 537 1820.500000 124505.5000 68.3908
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 4 5.000000 212.6600 42.5320
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 50 43.000000 2050.0000 47.6744
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 9 8.000000 400.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 84 65.250000 1631.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 2.000000 100.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 2 3.000000 150.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 15 13.500000 335.0000 24.8148
CONOF-CONOF-CONSULT, OT, FACE TO FACE 3 3.000000 150.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 2 2.000000 100.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 5 5.000000 125.0000 25.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 10 11.000000 275.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 5 10.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1013 6558.750000 327437.5000 49.9238
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 213 639.000000 31770.0000 49.7183
INTR-T1013-INTERPRETER 4 30.000000 2400.0000 80.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1114 7553.000000 75290.0000 9.9682
OCCT-97530-OT SESSION BY LICENSED OT 30 107.250000 7652.6300 71.3532
OCCT-97530GT-OT SESSION BY LICENSED OT 7 16.500000 1113.5900 67.4903
OCCT-97530HM-OT SESSION BY OT ASST 14 78.000000 3866.4000 49.5692
OCCT-97530HMGT-OT SESSION BY OT ASST 2 6.500000 371.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 41 165.500000 11762.0300 71.0697
PHY-97110GT-PT SESSION BY LICENSED PT 8 22.000000 1571.6800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 18 64.000000 3650.0400 57.0319
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 8 11.750000 671.6300 57.1600
SENS-V5060-BEHIND EAR HEARING AID 1 1.000000 228.0000 228.0000
SENS-V5264-EARMOLD 4 4.000000 66.6500 16.6625
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 95 344.750000 27603.2200 80.0674
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 54 157.000000 10762.9600 68.5539
Subtotal (Total Children Is Unduplicated) 1272 15931.75000 511822.0400 32.1259
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Total 23652.500000 854516.5400 36.1280
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Number of Children (Unduplicated) With at Least One Service 2262
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Center 06
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 8921 8660.250000 187509.4500 187509.4500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
17135 14656.250000 654593.5900 0.0000
Other 448 336.000000 12413.5000 0.0000
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Total 26504 23652.500000 854516.5400 187509.4500