CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2022 ending 06/30/2022 Date of Report:08/08/2022 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 1147 1810.750000 66942.2500 36.9693
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 43 41.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1253 2964.500000 109686.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1462 4816.500000 176628.7500 36.6716
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Screening, Eval, and Assessment,Class #02
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 57.4400 28.7200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 13.7100 13.7100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 20.8900 20.8900
AUDE-92652-AEP THRSHLD EST MLT FREQ I&R 1 1.000000 74.6000 74.6000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.000000 525.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 8.500000 637.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 8.000000 444.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 10 19.000000 1054.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 22.000000 1650.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 105 190.500000 14287.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 11.500000 862.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 97 175.500000 13162.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 14.500000 1087.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 72 123.000000 9225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 33 54.000000 2997.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 239 430.500000 23884.5000 55.4808
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 16.000000 1200.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 32 55.500000 4162.5000 75.0000
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 6.000000 315.4200 52.5700
Subtotal (Total Children Is Unduplicated) 349 1166.500000 77162.0600 66.1484
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 5.000000 2627.7900 525.5580
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 13 8.500000 425.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 15 15.250000 762.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 8 5.000000 250.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 141 94.000000 4700.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 23 23.250000 1162.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 101 69.500000 3475.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 4 3.000000 75.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 38 55.250000 2762.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 176 90.750000 4537.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 22 20.750000 1037.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 168 99.750000 4987.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 8 5.250000 131.2500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 297 906.250000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 324 1210.250000 60512.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 383 1358.500000 67925.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 507 2095.000000 20950.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 30 92.500000 6608.2000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 13 31.750000 2268.2200 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 33 99.500000 7108.2800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 33 85.500000 6108.1200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 19 110.500000 7894.1200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 14 33.250000 2375.3800 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 34 150.750000 10769.5800 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 16 26.250000 1875.3000 71.4400
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 41 161.250000 11519.7000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 40 102.750000 7340.4600 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 41 132.000000 9430.0800 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 52 166.250000 11876.9000 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 69 70.500000 2608.5000 37.0000
TRAV-TRAVS-Travel by mile 241 14585.00000 6488.3700 0.4449
Subtotal (Total Children Is Unduplicated) 775 21919.00000 270803.7500 12.3547
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Total 27902.000000 524594.5600 18.8013
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Number of Children (Unduplicated) With at Least One Service 1550
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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 19 28.500000 1916.0100 0.0000
P 670 728.250000 39823.6300 39823.6300
D 56 46.500000 2880.5800 0.0000
S 606 324.000000 12110.2500 0.0000
H 58 56.750000 2568.5100 0.0000
T 896 6309.000000 13790.9200 13790.9200
15015 20339.000000 448063.4300 0.0000
Other 82 69.000000 3366.2300 0.0000
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Total 17402 27901.000000 524519.5600 53614.5500