CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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 1140 1874.000000 69545.4000 37.1107
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 46 44.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1153 2523.500000 93818.3000 37.1778
Subtotal (Total Children Is Unduplicated) 1379 4442.250000 163363.7000 36.7750
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 1 1.000000 13.8000 13.8000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 7.2000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 57.8400 28.9200
EVAL-96111GT-DEVELOPMENTAL EVALUATION 3 5.500000 275.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 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 7.000000 525.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 6 12.500000 937.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 8.000000 444.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 9 14.000000 777.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 13.500000 1012.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 95 170.500000 12787.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 21.000000 1575.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 81 148.000000 11100.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 18.500000 1387.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 59 99.500000 7462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 69.000000 3829.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 192 348.000000 19314.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 21.500000 1612.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 59.500000 4400.0000 73.9496
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 1.000000 52.9300 52.9300
Subtotal (Total Children Is Unduplicated) 320 1039.000000 68869.7700 66.2847
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 71.9600 71.9600
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 17 19.000000 950.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 23 19.750000 987.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 0.250000 6.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 17 13.500000 675.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 161 133.500000 6662.5000 49.9064
CONIP-CONIP-CONSULT, ITDS PHONE 3 2.000000 50.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 45 53.250000 2662.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 81 63.750000 3187.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.250000 6.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 34 50.000000 2500.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 118 66.500000 3325.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 26 23.750000 1187.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 173 116.750000 5837.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 6 3.250000 81.2500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 380 1243.750000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 394 1684.250000 84212.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 245 577.250000 28862.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 611 2713.000000 27130.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 33 160.750000 11567.5700 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 9 16.000000 1151.3600 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 37 103.500000 7447.8600 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 23 38.000000 2734.4800 71.9600
PHY-97110-PT SESSION BY LICENSED PT 21 91.250000 6566.3500 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 5 11.000000 791.5600 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 44 224.250000 16137.0300 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 10 9.500000 683.6200 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 54 185.750000 13366.5700 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 30 42.750000 3076.2900 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 37 115.500000 8311.3800 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 21 46.750000 3364.1300 71.9600
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 39 40.250000 1489.2500 37.0000
TRAV-TRAVS-Travel by mile 288 18994.00000 8450.0100 0.4449
Subtotal (Total Children Is Unduplicated) 731 26864.00000 253533.1700 9.4377
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Total 32345.250000 485766.6400 15.0182
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Number of Children (Unduplicated) With at Least One Service 1497
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Center 53
Flag Claims Units Chgs Paid
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R 6 5.250000 246.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 601 564.500000 29660.8800 0.0000
P 2539 2410.500000 120903.8300 120850.4900
D 271 203.250000 10236.4300 0.0000
S 238 182.000000 7145.7000 0.0000
H 42 42.000000 2821.6300 0.0000
T 1318 11570.500000 17530.2700 17530.2700
12150 17164.750000 288356.1600 0.0000
Other 242 202.500000 8865.2400 0.0000
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Total 17407 32345.250000 485766.6400 138380.7600