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
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 818 598.500000 22264.2000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 94 72.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 665 1948.000000 72465.6000 37.2000
Subtotal (Total Children Is Unduplicated) 1228 2619.000000 94729.8000 36.1702
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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 3 5.500000 412.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 10.000000 750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 9.000000 675.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 18 36.000000 2700.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 13.000000 975.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 9 17.000000 1275.0000 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 55.500000 3080.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 16.000000 1200.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 31.000000 2325.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 93 249.000000 16610.2100 66.7077
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 20 41.000000 5073.5700 123.7456
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 1448.500000 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 49 181.500000 9075.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 30 95.000000 4750.0000 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 13 35.000000 2518.6000 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 8 17.000000 1223.3200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 20 88.000000 6332.4800 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 4 5.500000 395.7800 71.9600
SENS-V5264-EARMOLD 1 2.000000 36.2600 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 123.750000 8905.0500 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 10 15.500000 1115.3800 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 287.8400 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 143.9200 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) 930 35068.75000 135010.0100 3.8499
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Total 37936.750000 246350.0200 6.4937
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Number of Children (Unduplicated) With at Least One Service 1527
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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 149 105.500000 4938.7200 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2424 18062.250000 38464.2200 38464.2200
11199 19729.500000 201402.0800 0.0000
Other 56 39.500000 1545.0000 0.0000
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Total 13828 37936.750000 246350.0200 38464.2200