CMS/EIP Fiscal Report Center: 09
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 1965 6320.000000 233803.0000 36.9941
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 3.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1976 7667.750000 283688.2500 36.9976
Subtotal (Total Children Is Unduplicated) 2142 13990.75000 517491.2500 36.9881
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 104 170.250000 8512.5000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 17 33.000000 2475.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 12 21.500000 1612.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 10 19.500000 1462.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 30 56.500000 3085.7500 54.6150
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 323 592.500000 44287.5000 74.7468
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 179 325.500000 24372.5000 74.8771
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 141 265.500000 19912.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 19.500000 1082.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 456 827.500000 45653.2000 55.1700
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 15.000000 1125.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 64 123.000000 9225.0000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 1 4.000000 200.0000 50.0000
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 31.0500 31.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 5 5.000000 255.2500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 17 18.000000 893.3800 49.6322
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 184.2000 46.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 2 2.000000 102.1000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 5 5.000000 222.7500 44.5500
Subtotal (Total Children Is Unduplicated) 721 2526.750000 165894.4300 65.6553
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 3.000000 199.5000 66.5000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 91 129.250000 6462.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 49 92.000000 4600.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 100 124.250000 3106.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 14 15.000000 750.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 14 19.000000 950.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 20 23.000000 1150.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 9 11.000000 550.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 15 15.000000 750.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 2 2.000000 100.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 2.000000 50.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 14 16.000000 800.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 12 18.000000 900.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 7.000000 350.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 968 7037.500000 351875.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 59 251.000000 12550.0000 50.0000
INTR-T1013-INTERPRETER 85 305.750000 15237.5000 49.8365
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 33 190.000000 1900.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 165 975.250000 69478.9400 71.2422
OCCT-97530GT-OT SESSION BY LICENSED OT 6 23.000000 1603.1200 69.7009
OCCT-97530TLGT-OT SESSION BY LICENSED OT 5 30.500000 2178.9200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 173 1226.000000 87125.0900 71.0645
PHY-97110GT-PT SESSION BY LICENSED PT 34 221.000000 15788.2400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 424 3143.750000 223855.7700 71.2066
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 40 205.000000 14189.1600 69.2154
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 3 20.000000 1428.8000 71.4400
TRAV-TRAVS-Travel by mile 1096 115089.0000 50518.9000 0.4390
Subtotal (Total Children Is Unduplicated) 1465 129196.2500 868497.6900 6.7223
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Total 145713.750000 1551883.3700 10.6502
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Number of Children (Unduplicated) With at Least One Service 2208
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Center 09
Flag Claims Units Chgs Paid
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R 10 8.500000 314.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1095 1172.500000 47257.2600 37.0000
P 14484 94115.250000 759882.1100 760186.5750
D 11 11.000000 550.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 300 459.500000 26777.0000 0.0000
T 13 15.750000 808.7500 729.5000
7544 49329.750000 675090.7500 225.0000
Other 328 601.500000 41203.0000 0.0000
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Total 23785 145713.750000 1551883.3700 761178.0750