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
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 1037 1558.750000 57669.9000 36.9975
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 38 39.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 491 749.500000 27731.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1155 2348.000000 85401.4000 36.3720
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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 1 1.000000 19.5100 19.5100
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 22.0700 22.0700
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.9200 28.9200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 20.8900 20.8900
EVAL-96111GT-DEVELOPMENTAL EVALUATION 5 8.000000 400.0000 50.0000
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 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 6.500000 487.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 8 12.000000 900.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 8.000000 600.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 20 36.000000 1998.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 37 82.500000 4984.8900 60.4229
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EI Services,Class #03
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 1020.500000 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 44 170.000000 8500.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 20 56.500000 2825.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 590 2346.000000 23460.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 8 27.500000 1965.3800 71.4684
OCCT-97530GT-OT SESSION BY LICENSED OT 4 5.000000 357.2000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 43.500000 3111.2800 71.5237
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 16.000000 1144.6000 71.5375
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) 679 20341.25000 72239.7900 3.5514
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Total 22771.750000 162626.0800 7.1416
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Number of Children (Unduplicated) With at Least One Service 1378
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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 88 47.000000 1824.5900 0.0000
S 321 170.250000 6444.2500 0.0000
H 1 0.250000 12.5000 0.0000
T 1427 11917.500000 19212.4000 19212.4000
8611 10582.750000 133134.3400 0.0000
Other 70 54.000000 1998.0000 0.0000
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Total 10518 22771.750000 162626.0800 19212.4000