CMS/EIP Fiscal Report Center: 07
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 Page: 1
List order: No List
Payclass Filters:GR
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 1552 1870.250000 69199.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 54 58.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 539 1193.750000 44094.7500 36.9380
Subtotal (Total Children Is Unduplicated) 1639 3122.000000 113294.0000 36.2889
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 29.1600 14.5800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 29.3700 9.7900
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.000000 98.7200 24.6800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 37.0600 12.3533
EXIT-EXIT-EXIT ASSESSMENT 20 31.500000 1575.0000 50.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 8.000000 444.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 5.827160 437.0370 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 47 94.000000 5217.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 54 107.500000 5966.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 42.000000 3150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 25.230900 1892.3175 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 143 336.058060 19500.0145 58.0257
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 57 58.000000 2900.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 97 98.750000 4937.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 14 11.750000 293.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 186 247.000000 12350.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 159 261.750000 13087.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 111 135.500000 6775.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 85 101.750000 5087.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 35 41.750000 2087.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 26 29.250000 1462.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 64 75.750000 3787.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 75 79.000000 3950.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 2.000000 50.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 54 171.250000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 25 80.000000 4000.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 315 1371.500000 68532.0000 49.9686
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 72 173.750000 8687.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1208 6594.000000 66660.0000 10.1092
OCCT-97530-OT SESSION BY LICENSED OT 3 11.000000 378.3400 34.3945
PHY-97110-PT SESSION BY LICENSED PT 4 6.000000 394.5300 65.7550
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 21 68.000000 3675.9800 54.0585
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 100.3800 50.1900
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 3 5.500000 203.5000 37.0000
TRAV-TRAVS-Travel by mile 23 996.000000 443.0100 0.4448
Subtotal (Total Children Is Unduplicated) 1310 10623.75000 209952.9300 19.7626
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Total 14081.808060 342746.9445 24.3397
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Number of Children (Unduplicated) With at Least One Service 2142
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Center 07
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 4213 10569.000000 216059.3400 216050.3400
D 14 11.750000 623.7500 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
6482 3501.058060 126063.8545 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 10709 14081.808060 342746.9445 216050.3400