CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2022 ending 09/30/2022 Date of Report:10/18/2022 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 1039 1561.750000 57781.5000 36.9979
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 38 39.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1147 2364.250000 87431.0000 36.9804
Subtotal (Total Children Is Unduplicated) 1328 3965.750000 145212.5000 36.6167
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 2.000000 97.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.000000 39.0200 19.5100
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 22.0700 22.0700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 14.4000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 5.000000 144.6000 28.9200
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 44.7600 44.7600
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 20.8900 20.8900
EVAL-96111GT-DEVELOPMENTAL EVALUATION 5 8.000000 400.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 8 14.500000 1087.5000 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 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 13 27.500000 1526.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 25.000000 1875.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 74 138.000000 10350.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 15.500000 1162.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 66 115.000000 8587.5000 74.6739
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 14.000000 1050.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 54 89.000000 6675.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 21.500000 1193.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 173 307.000000 17038.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 11.500000 862.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 24.500000 1837.5000 75.0000
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 2.000000 105.1400 52.5700
Subtotal (Total Children Is Unduplicated) 265 863.000000 56794.3800 65.8104
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 3.000000 214.3200 71.4400
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 3.750000 187.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 10 6.750000 337.5000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 10 9.000000 450.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 134 108.750000 5425.0000 49.8851
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 20 21.500000 1075.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 85 54.250000 2712.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 1.500000 37.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 34 44.750000 2237.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 160 71.250000 3550.0000 49.8246
CONPP-CONPP-CONSULT, PT, PHONE 6 1.750000 43.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 22 22.750000 1137.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 158 85.750000 4287.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 5 4.000000 100.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 350 1021.250000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 379 1360.250000 68012.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 270 744.500000 37225.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 590 2346.000000 23460.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 35 101.750000 7306.5600 71.8089
OCCT-97530GT-OT SESSION BY LICENSED OT 14 18.000000 1285.9200 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 21 53.250000 3808.0800 71.5132
OCCT-97530TLGT-OT SESSION BY LICENSED OT 9 16.000000 1143.0400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 23 120.500000 8616.8400 71.5090
PHY-97110GT-PT SESSION BY LICENSED PT 8 11.750000 839.4200 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 37 197.750000 14138.1800 71.4952
PHY-97110TLGT-PT SESSION BY LICENSED PT 11 17.500000 1250.2000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 47 184.500000 13197.7100 71.5323
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 26 67.750000 4845.2600 71.5168
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 48 207.250000 14855.9900 71.6815
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 28 74.750000 5345.3400 71.5096
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 68 49.500000 1831.5000 37.0000
TRAV-TRAVS-Travel by mile 280 16166.00000 7174.2600 0.4438
Subtotal (Total Children Is Unduplicated) 752 23199.00000 236206.3700 10.1817
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Total 28027.750000 438213.2500 15.6350
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Number of Children (Unduplicated) With at Least One Service 1495
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Center 53
Flag Claims Units Chgs Paid
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R 65 59.500000 3278.9100 0.0000
U 0 0.000000 0.0000 0.0000
B 1392 1336.500000 68633.7600 9.2500
P 1289 1207.000000 57601.6300 57592.3800
D 155 109.500000 5704.1500 0.0000
S 412 256.500000 11311.3000 0.0000
H 6 4.500000 316.1200 0.0000
T 1441 11931.500000 19912.4000 19912.4000
10985 13010.250000 266868.9000 0.0000
Other 149 112.500000 4586.0800 9.2500
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Total 15894 28027.750000 438213.2500 77523.2800