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
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 2734 7000.250000 258898.2500 36.9841
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 101 107.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1224 3608.750000 133514.5000 36.9974
Subtotal (Total Children Is Unduplicated) 2956 10716.25000 392412.7500 36.6185
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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 5 5.000000 102.3400 20.4680
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.4900 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 27.7400 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 18.8700 9.4350
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 11 13.000000 366.2400 28.1723
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 30.4100 15.2050
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-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 7.000000 525.0000 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 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 36 59.500000 4462.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 59 103.500000 7762.5000 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 19 31.500000 2362.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 12.500000 693.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 97 174.500000 9684.7500 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 17 32.000000 2400.0000 75.0000
Subtotal (Total Children Is Unduplicated) 183 488.000000 31150.9400 63.8339
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 6.000000 4698.5400 783.0900
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-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 49 260.000000 13000.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 102 620.750000 31037.5000 50.0000
INTR-T1013-INTERPRETER 1 12.000000 900.0000 75.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 672 4047.000000 40470.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 8 83.750000 5983.1000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 17 72.500000 5179.4000 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 4 5.000000 357.2000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 5 14.750000 1053.7400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 6 27.000000 1928.8800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 6 9.726444 694.8572 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 4 19.000000 1357.3600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 3 4.500000 321.4800 71.4400
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 18 47.500000 3393.4000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 19 117.250000 8376.3400 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 5 14.000000 1000.1600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 7 27.750000 1982.4600 71.4400
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) 1103 31138.47644 241941.9072 7.7699
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Total 42342.726444 665505.5972 15.7171
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Number of Children (Unduplicated) With at Least One Service 3000
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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 2 1.500000 89.9400 0.0000
P 10 6.250000 256.2500 166.5000
D 307 281.750000 14378.2600 0.0000
S 601 277.750000 10425.1300 92.5000
H 0 0.000000 0.0000 0.0000
T 2501 13983.726444 61364.0172 61364.0200
30150 27690.000000 574879.0600 0.0000
Other 110 95.250000 3625.4400 0.0000
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Total 33681 42336.226444 665018.0972 61623.0200