CMS/EIP Fiscal Report Center: 57
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 760 664.250000 24710.1000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 613 2727.000000 101423.7000 37.1924
Subtotal (Total Children Is Unduplicated) 1088 3391.250000 126133.8000 37.1939
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.5100 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 14.6800 14.6800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.9200 28.9200
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 45.0800 45.0800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 13.8100 13.8100
EXIT-EXIT-EXIT ASSESSMENT 8 21.000000 1050.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 56 97.500000 7312.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 14 26.000000 1950.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 8 14.000000 1050.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 71 130.000000 7215.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 12.000000 900.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 6 6.000000 308.4600 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 257.0500 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 101 332.000000 21070.5400 63.4655
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
CONOF-CONOF-CONSULT, OT, FACE TO FACE 65 68.000000 3400.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 62 62.250000 3112.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 4.000000 200.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 7 7.000000 350.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 43 45.250000 2262.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 88 90.000000 4500.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 5 30.000000 1500.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 332 2143.000000 107150.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 20 54.500000 2725.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1020 7529.000000 75290.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 57.750000 4070.6900 70.4881
PHY-97110-PT SESSION BY LICENSED PT 5 21.500000 1547.1400 71.9600
PHY-97110HM-PT SESSION BY PT ASST 2 3.000000 172.6800 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 128.500000 9246.8600 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 8.000000 575.6800 71.9600
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 1 1.000000 37.0000 37.0000
TRAV-TRAVS-Travel by mile 9 1882.000000 837.4600 0.4450
Subtotal (Total Children Is Unduplicated) 1044 12134.75000 216977.5100 17.8807
-----------------------------------------------------------------------------------------------------------------------
Total 15858.000000 364181.8500 22.9652
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1621
-----------------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 0 0.000000 0.0000 0.0000
S 12 36.000000 480.0000 480.0000
H 5 5.000000 122.0000 122.0000
T 3110 12096.750000 216896.4600 216896.4600
3550 3705.250000 146493.3900 287.8400
Other 7 15.000000 190.0000 190.0000
---------------------------------------------------------
Total 6684 15858.000000 364181.8500 217976.3000