CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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 818 643.000000 23897.6500 37.1659
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 93 69.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1602 5209.750000 193513.5000 37.1445
Subtotal (Total Children Is Unduplicated) 1650 5921.750000 217411.1500 36.7140
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 16 19.000000 1221.3000 64.2789
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.000000 56.1000 56.1000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.5100 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 5.000000 73.4000 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.000000 36.0000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 86.7600 28.9200
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 45.0800 45.0800
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.000000 90.6400 45.3200
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 15.500000 1162.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 18 34.000000 2550.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 7.000000 525.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 6 12.000000 900.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 13.000000 721.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 20 38.500000 2136.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 27.000000 2025.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 47 94.000000 7050.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 46.000000 3450.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 89 166.500000 12487.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 38.000000 2812.5000 74.0132
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 49 89.000000 6675.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 57.500000 3191.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 147 285.000000 15817.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 48.500000 3637.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 73 154.500000 11587.5000 75.0000
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 358 1189.000000 80283.2900 67.5217
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 19 50.000000 4455.6600 89.1132
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 63 50.250000 2512.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 151 171.000000 8550.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 44 29.250000 1450.0000 49.5726
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 231 118.250000 5900.0000 49.8943
CONOF-CONOF-CONSULT, OT, FACE TO FACE 26 26.000000 1300.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 286 132.000000 6587.5000 49.9053
CONPF-CONPF-CONSULT, PT, FACE TO FACE 33 33.000000 1650.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 218 86.750000 4337.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 51 63.750000 3187.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 198 103.500000 5175.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.500000 12.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 426 1304.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 403 1573.750000 78687.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 314 838.750000 41937.5000 50.0000
INTR-T1013-INTERPRETER 9 44.000000 1913.7500 43.4943
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 737 3120.000000 31200.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 49 161.750000 11639.5300 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 26 36.000000 2590.5600 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 51 225.250000 16208.9900 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 23 45.500000 3274.1800 71.9600
PHY-97110-PT SESSION BY LICENSED PT 65 249.500000 17954.0200 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 15 24.000000 1727.0400 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 45 191.250000 13762.3500 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 13 16.000000 1151.3600 71.9600
SENS-V5264-EARMOLD 2 3.000000 54.3900 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 72 340.000000 24466.4000 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 20 29.250000 2104.8300 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 31 114.500000 8177.4600 71.4189
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 16 43.000000 3094.2800 71.9600
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.9600 13.9600
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 75 72.750000 2691.7500 37.0000
TRAV-TRAVS-Travel by mile 391 21923.00000 9733.1200 0.4440
Subtotal (Total Children Is Unduplicated) 957 31220.50000 317501.1300 10.1696
-----------------------------------------------------------------------------------------------------------------------
Total 38331.250000 615195.5700 16.0495
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1692
-----------------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 39 43.000000 2752.9200 0.0000
U 0 0.000000 0.0000 0.0000
B 1148 1093.750000 51758.8600 46.5000
P 4110 3651.000000 167992.6100 167775.1000
D 268 234.750000 12038.5900 0.0000
S 0 0.000000 0.0000 0.0000
H 23 22.500000 1619.1000 0.0000
T 2273 13635.510000 40264.5400 39814.5400
12754 19530.740000 333548.5400 0.0000
Other 155 119.500000 5201.8100 1285.9500
---------------------------------------------------------
Total 20770 38330.750000 615176.9700 208922.0900