CMS/EIP Fiscal Report Center: 53
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 1113 1693.500000 62659.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 18 12.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1175 2782.750000 102887.7500 36.9734
Subtotal (Total Children Is Unduplicated) 1372 4489.000000 165547.2500 36.8784
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.7900 9.7900
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 57.4400 28.7200
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 9.000000 675.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 3.000000 225.0000 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 5 9.500000 527.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 12.500000 693.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 6.500000 487.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 114 198.500000 14887.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 85 150.000000 11250.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 55 88.500000 6637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 17.500000 971.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 165 287.000000 15928.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 56.000000 4200.0000 75.0000
Subtotal (Total Children Is Unduplicated) 296 865.000000 58350.4800 67.4572
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 6 4.500000 225.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 17 16.500000 825.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 9 6.250000 312.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 142 112.750000 5637.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 2.000000 50.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 24 23.750000 1162.5000 48.9474
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 116 97.000000 4837.5000 49.8711
CONOP-CONOP-CONSULT, OT, PHONE 8 7.250000 181.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 31 55.000000 2750.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 179 116.750000 5787.5000 49.5717
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 24 21.500000 1075.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 173 104.000000 5200.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 3 1.750000 43.7500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 179 693.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 101 278.500000 13925.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 373 1485.500000 74275.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 204 763.000000 7630.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 20 72.500000 5179.4000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 20 54.500000 3893.4800 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 21 87.500000 6251.0000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 37 99.000000 7072.5600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 15 88.000000 6286.7200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 16 35.250000 2518.2600 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 31 114.500000 8179.8800 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 27 56.500000 4036.3600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 33 96.500000 6893.9600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 40 179.750000 12841.3400 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 29 63.500000 4536.4000 71.4394
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 72 288.500000 20610.4400 71.4400
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.8800 13.8800
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 64 63.250000 2340.2500 37.0000
TRAV-TRAVS-Travel by mile 27 597.000000 265.6100 0.4449
Subtotal (Total Children Is Unduplicated) 693 5686.500000 214837.0400 37.7802
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Total 11040.500000 438734.7700 39.7387
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Number of Children (Unduplicated) With at Least One Service 1468
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Center 53
Flag Claims Units Chgs Paid
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R 36 35.000000 1415.8800 0.0000
U 0 0.000000 0.0000 0.0000
B 1668 1578.500000 79670.1100 9.2500
P 743 728.500000 34954.0200 34954.0600
D 35 32.750000 2219.1200 0.0000
S 293 151.750000 6201.3900 0.0000
H 0 0.000000 0.0000 0.0000
T 140 492.500000 5306.8600 5306.8600
10105 7727.250000 295577.5600 0.0000
Other 388 294.250000 13389.8300 0.0000
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Total 13408 11040.500000 438734.7700 40270.1700