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
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 1113 1693.500000 62659.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 18 12.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 403 734.250000 27158.0000 36.9874
Subtotal (Total Children Is Unduplicated) 1227 2440.500000 89817.5000 36.8029
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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 1 1.000000 28.7200 28.7200
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 12.500000 937.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 14 26.000000 1950.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 17 30.000000 1665.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 12.500000 937.5000 75.0000
Subtotal (Total Children Is Unduplicated) 32 93.500000 6277.0100 67.1338
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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 142 112.500000 5625.0000 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 179 691.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 9.000000 450.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 35 112.500000 5625.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 204 763.000000 7630.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 25.750000 1839.5800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 5 11.750000 839.4200 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 3.000000 214.3200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 3 8.000000 571.5200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.000000 142.8800 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 0.500000 35.7200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 7.500000 535.8000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 22.000000 1571.6800 71.4400
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) 444 2885.250000 50136.7800 17.3769
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Total 5419.250000 146231.2900 26.9837
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Number of Children (Unduplicated) With at Least One Service 1311
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Center 53
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 0 0.000000 0.0000 0.0000
D 7 6.000000 325.3200 0.0000
S 197 80.500000 3012.9400 0.0000
H 0 0.000000 0.0000 0.0000
T 123 475.500000 4456.8600 4456.8600
7195 4813.750000 136835.9200 0.0000
Other 56 43.500000 1600.2500 0.0000
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Total 7578 5419.250000 146231.2900 4456.8600