CMS/EIP Fiscal Report Center: 54
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 818 598.500000 22264.2000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 94 72.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1621 5840.250000 217248.0000 37.1984
Subtotal (Total Children Is Unduplicated) 1664 6511.250000 239512.2000 36.7844
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 15 16.000000 776.0000 48.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 14.6800 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 7.2000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.9200 28.9200
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.000000 525.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 7 13.500000 1012.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 14 27.500000 2062.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 5 10.000000 750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 6.500000 487.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 9.000000 499.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 18 34.500000 1914.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 22.500000 1687.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 67 123.000000 9225.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 32.500000 2437.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 121 230.000000 17250.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 22 38.000000 2850.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 71 131.500000 9862.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 35 63.000000 3496.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 193 378.000000 20979.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 38 74.500000 5587.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 89 189.500000 14212.5000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 416 1420.500000 96467.9600 67.9113
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 26 55.000000 6792.0700 123.4922
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 54 51.250000 2562.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 151 157.250000 7862.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 0.500000 12.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 37 40.000000 2000.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 280 158.250000 7912.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 28 30.000000 1500.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 295 131.000000 6537.5000 49.9046
CONOP-CONOP-CONSULT, OT, PHONE 2 1.500000 37.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 40 41.500000 2075.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 251 93.750000 4687.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.250000 6.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 59 74.750000 3737.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 184 97.250000 4862.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.500000 12.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 484 1450.750000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 438 1803.000000 90150.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 303 784.500000 39225.0000 50.0000
INTR-T1013-INTERPRETER 10 38.750000 1405.0000 36.2581
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 812 3552.000000 35520.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 56 171.000000 12305.1600 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 24 47.750000 3436.0900 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 60 248.500000 17882.0600 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 25 67.000000 4821.3200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 68 297.250000 21390.1100 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 13 18.500000 1331.2600 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 48 210.000000 15111.6000 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 13 22.750000 1637.0900 71.9600
SENS-V5264-EARMOLD 1 2.000000 36.2600 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 76 353.250000 25419.8700 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 26 39.250000 2824.4300 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 36 130.750000 9408.7700 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 21 49.750000 3580.0100 71.9600
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 42 44.500000 1646.5000 37.0000
TRAV-TRAVS-Travel by mile 426 28495.00000 12675.0600 0.4448
Subtotal (Total Children Is Unduplicated) 1004 38761.00000 350503.9100 9.0427
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Total 46692.750000 686484.0700 14.7022
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Number of Children (Unduplicated) With at Least One Service 1740
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Center 54
Flag Claims Units Chgs Paid
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R 16 18.750000 842.6200 0.0000
U 0 0.000000 0.0000 0.0000
B 1083 1029.500000 50927.2200 109.1600
P 4842 4540.750000 208083.0300 207779.7200
D 238 203.250000 11113.3000 0.0000
S 0 0.000000 0.0000 0.0000
H 83 87.000000 5855.6900 0.0000
T 2579 18226.750000 47678.4400 47678.4400
13692 22458.750000 356309.3700 0.0000
Other 162 128.000000 5674.4000 889.7200
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Total 22695 46692.750000 686484.0700 256457.0400