CMS/EIP Fiscal Report Center: 52
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 343 158.000000 5836.7500 36.9415
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 58 35.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 710 2264.000000 83388.7500 36.8325
Subtotal (Total Children Is Unduplicated) 763 2457.750000 89225.5000 36.3037
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 12.000000 666.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 157 318.000000 23618.1500 74.2709
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 69 142.000000 10310.0000 72.6056
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 29 57.000000 4275.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 35 72.000000 5230.0000 72.6389
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 16.000000 858.2000 53.6375
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 130 259.000000 14374.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 7 14.000000 777.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97165TL-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 25 26.000000 1250.0000 48.0769
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 459.4500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 357.3500 51.0500
Subtotal (Total Children Is Unduplicated) 244 982.000000 65542.4500 66.7438
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 43 45.500000 2275.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 68 71.500000 3550.0000 49.6503
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 28 21.500000 537.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 63 81.500000 4075.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 7 7.500000 375.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 4 2.000000 50.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 40 72.000000 3600.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 9 8.000000 400.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 2.000000 50.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 22 50.750000 2537.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 2 2.000000 100.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 3 2.000000 50.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 46 48.750000 2437.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 3 2.500000 125.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.250000 6.2500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 117 196.000000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 392 1953.750000 97150.1000 49.7249
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 23 28.250000 1412.5000 50.0000
INTR-T1013-INTERPRETER 1 8.000000 400.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 551 3128.000000 31280.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 45.750000 3268.3800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 11 18.500000 1321.6400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 10 33.000000 1887.6000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 24 113.000000 8072.7200 71.4400
OCCT-97530TLHM-OT SESSION BY OT ASST 10 26.500000 1515.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 22 74.750000 5340.1400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 7 8.000000 571.5200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 6 34.000000 1943.4400 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 5.000000 285.8000 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 25 80.250000 5733.0600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 5 11.000000 785.8400 71.4400
PHY-97110TLHM-PT SESSION BY PT ASST 3 21.250000 1214.6500 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 114 600.250000 40106.3000 66.8160
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 10 24.750000 1768.1400 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 93 410.000000 29204.6400 71.2308
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 9 19.500000 1393.0800 71.4400
TRAV-TRAVS-Travel by mile 476 30697.00000 13658.0400 0.4449
Subtotal (Total Children Is Unduplicated) 700 37956.25000 268589.3400 7.0763
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Total 41396.000000 423357.2900 10.2270
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Number of Children (Unduplicated) With at Least One Service 919
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Center 52
Flag Claims Units Chgs Paid
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R 42 43.000000 2416.5200 0.0000
U 0 0.000000 0.0000 0.0000
B 576 633.750000 31148.8300 37.0000
P 1656 1771.750000 80293.1800 78916.5400
D 177 201.250000 10376.5000 0.0000
S 33 39.750000 1706.6300 59.2500
H 94 120.750000 7581.7500 46.7500
T 3671 34809.000000 110632.3500 104957.3400
3319 3774.000000 179099.7800 2359.8600
Other 4 2.750000 101.7500 0.0000
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Total 9572 41396.000000 423357.2900 186376.7400