CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2021 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 2734 7000.250000 258898.2500 36.9841
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 101 107.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2941 12491.00000 462120.7500 36.9963
Subtotal (Total Children Is Unduplicated) 3178 19598.50000 721019.0000 36.7895
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.000000 97.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 6 6.000000 125.8400 20.9733
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.4900 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.000000 42.3200 14.1067
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 18.8700 9.4350
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 14 16.000000 452.4000 28.2750
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 30.4100 15.2050
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
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 4 8.000000 400.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 3 5.000000 250.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 15.000000 1125.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 23 42.500000 3187.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 9.500000 712.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 24 42.000000 3150.0000 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 7 12.500000 937.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 9 18.000000 1350.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 17.500000 971.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 51 99.000000 5494.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 35.500000 2662.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 426 759.500000 57150.0000 75.2469
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 24 41.500000 3112.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 388 698.500000 52387.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 21.000000 1575.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 203 336.000000 25200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 69 112.500000 6243.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 796 1416.500000 78607.5000 55.4942
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 19.000000 1425.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 140 255.000000 19125.0000 75.0000
SPCH-92522GT-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 2.000000 102.1000 51.0500
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 6.000000 315.4200 52.5700
Subtotal (Total Children Is Unduplicated) 1197 4013.000000 266821.3900 66.4893
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 10.000000 7318.9400 731.8940
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 28 20.750000 1037.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 75 68.250000 3412.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 9 6.250000 156.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 38 29.000000 1450.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 448 461.250000 23062.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 19 8.250000 206.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 74 77.000000 3850.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 372 385.000000 19250.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 29 19.500000 487.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 76 157.500000 7875.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 467 346.750000 17337.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 8 2.000000 50.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 69 67.250000 3362.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 488 376.250000 18812.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 16 12.500000 312.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 430 2340.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 1.250000 31.2500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 439 2277.500000 113875.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 858 8221.250000 411049.5000 49.9984
INTR-T1013-INTERPRETER 1 14.000000 1050.0000 75.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 672 4047.000000 40470.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 68 296.500000 21181.9600 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 63 350.750000 25854.6200 73.7124
OCCT-97530TL-OT SESSION BY LICENSED OT 44 235.750000 17284.7800 73.3183
OCCT-97530TLGT-OT SESSION BY LICENSED OT 91 532.750000 38126.0800 71.5647
PHY-97110-PT SESSION BY LICENSED PT 39 306.500000 21896.3600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 35 168.750109 12055.5079 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 56 361.250000 25807.7000 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 53 212.750000 15198.8600 71.4400
SENS-V5264-EARMOLD 2 5.000000 90.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 75 389.950000 27858.7000 71.4417
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 82 680.280000 48659.0200 71.5279
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 71 363.800000 25989.1600 71.4380
CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2021 ending 06/30/2022 Date of Report:08/08/2022 Page: 2
List order: No List
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 130 1043.000000 74454.3600 71.3848
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 210 273.250000 10110.2500 37.0000
TRAV-TRAVS-Travel by mile 294 21097.00000 9385.4900 0.4449
Subtotal (Total Children Is Unduplicated) 1408 45268.78011 1048560.0379 23.1630
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Total 68880.280109 2036400.4279 29.5643
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Number of Children (Unduplicated) With at Least One Service 3201
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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 182 196.750000 11210.3500 710.7500
P 12638 11815.780000 575631.5900 574435.0900
D 604 567.250000 33784.0700 0.0000
S 965 522.250000 20522.0900 92.5000
H 158 141.000000 7173.1900 9.2500
T 2846 14334.181244 79309.1372 79309.1400
42667 40340.318865 1250600.1307 0.0000
Other 1003 950.250000 57232.3700 296.0000
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Total 61063 68867.780109 2035462.9279 654852.7300