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
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 818 643.000000 23897.6500 37.1659
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 93 69.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 677 1746.250000 64857.5500 37.1410
Subtotal (Total Children Is Unduplicated) 1225 2458.250000 88755.2000 36.1050
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 15 17.000000 824.5000 48.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 29.3600 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 14.4000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 57.8400 28.9200
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.3200 45.3200
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 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 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 14 26.000000 1950.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 12 22.000000 1650.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 9.500000 527.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 28 55.000000 3052.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 13.000000 975.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 17.500000 1312.5000 75.0000
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 72 199.500000 12734.1700 63.8304
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 12 33.000000 3232.3400 97.9497
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 425 1299.750000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 45 181.000000 9050.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 36 84.000000 4200.0000 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 10 31.500000 2266.7400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 6 8.500000 611.6600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 18 83.500000 6008.6600 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 5 7.000000 503.7200 71.9600
SENS-V5264-EARMOLD 1 1.000000 18.1300 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 22 134.000000 9642.6400 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 9.000000 647.6400 71.9600
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) 886 27846.25000 122382.6500 4.3949
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Total 30504.000000 223872.0200 7.3391
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Number of Children (Unduplicated) With at Least One Service 1476
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Center 54
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 130 89.250000 3977.7400 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2161 13516.500000 33694.8400 33244.8400
10295 16869.250000 185046.0400 0.0000
Other 39 28.500000 1134.8000 0.0000
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Total 12625 30503.500000 223853.4200 33244.8400