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
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 1147 1810.750000 66942.2500 36.9693
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 43 41.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 462 830.500000 30728.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1269 2682.500000 97670.7500 36.4103
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Screening, Eval, and Assessment,Class #02
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.7200 28.7200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 13.7100 13.7100
AUDE-92652-AEP THRSHLD EST MLT FREQ I&R 1 1.000000 74.6000 74.6000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 10 15.000000 1125.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 15 25.000000 1875.0000 75.0000
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 5 8.500000 637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 36 64.500000 3579.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.500000 562.5000 75.0000
Subtotal (Total Children Is Unduplicated) 54 145.500000 9342.0300 64.2064
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 4.000000 1433.5100 358.3775
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-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 32 137.000000 6850.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 36 106.750000 5337.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 507 2095.000000 20950.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 23.000000 1643.1200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 1 5.000000 357.2000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 7.000000 500.0800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 12.000000 857.2800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 7 21.000000 1500.2400 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) 621 18463.75000 72857.0500 3.9460
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Total 21291.750000 179869.8300 8.4479
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Number of Children (Unduplicated) With at Least One Service 1401
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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 10 7.000000 317.0000 0.0000
S 367 175.000000 6465.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 874 6287.000000 12690.9200 12690.9200
9347 14791.500000 159239.9100 0.0000
Other 34 31.250000 1156.2500 0.0000
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Total 10632 21291.750000 179869.8300 12690.9200