CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 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 1227 2081.000000 77143.3500 37.0703
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 17 13.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1298 2844.500000 105377.9000 37.0462
Subtotal (Total Children Is Unduplicated) 1492 4939.000000 182521.2500 36.9551
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 3 3.000000 145.5000 48.5000
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 3 3.000000 47.5200 15.8400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.000000 115.6800 28.9200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 27.6200 13.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 21.0400 21.0400
BEHV-BEHV-BEHAVIORAL ASSESSMENT 1 2.000000 250.0000 125.0000
EXIT-EXIT-EXIT ASSESSMENT 4 8.000000 400.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 7 11.000000 825.0000 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 3 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 16 30.500000 1692.7500 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 100 168.000000 12487.5000 74.3304
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 7.500000 562.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 84 139.000000 10425.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 18.000000 1350.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 87 134.500000 10087.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 43.500000 2414.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 210 347.500000 19286.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 14.000000 1050.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 28.500000 2137.5000 75.0000
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 7.000000 368.9900 52.7129
Subtotal (Total Children Is Unduplicated) 340 1021.000000 67262.3500 65.8789
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 8 15.000000 9661.8600 644.1240
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 6 4.500000 225.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 23 20.000000 1000.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 16 14.750000 737.5000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 147 121.250000 6062.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.250000 6.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 41 56.500000 2825.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 78 53.000000 2600.0000 49.0566
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 29 35.750000 1787.5000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 166 98.750000 4925.0000 49.8734
CONPP-CONPP-CONSULT, PT, PHONE 3 1.250000 31.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 30 29.250000 1462.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 137 86.000000 4300.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 7 2.750000 68.7500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 386 1184.250000 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 405 1835.000000 91650.0000 49.9455
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 288 636.500000 31825.0000 50.0000
INTR-T1013-INTERPRETER 1 1.000000 50.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 654 3161.000000 31610.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 54 221.000000 15903.1600 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 18 30.500000 2172.8200 71.2400
OCCT-97530TL-OT SESSION BY LICENSED OT 32 99.000000 7124.0400 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 7 12.500000 899.5000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 31 164.250000 11819.4300 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 5 5.000000 359.8000 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 62 281.000000 20184.7800 71.8320
PHY-97110TLGT-PT SESSION BY LICENSED PT 14 17.500000 1259.3000 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 45 218.000000 16039.4400 73.5754
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 21 29.750000 2140.8100 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 42 198.250000 14266.0700 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 21 45.500000 3274.1800 71.9600
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 40 63.000000 2331.0000 37.0000
TRAV-TRAVS-Travel by mile 304 18287.00000 8134.9500 0.4448
Subtotal (Total Children Is Unduplicated) 776 27032.00000 296862.3900 10.9819
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Total 32992.000000 546645.9900 16.5690
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Number of Children (Unduplicated) With at Least One Service 1603
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Center 53
Flag Claims Units Chgs Paid
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R 115 114.500000 7888.4100 0.0000
U 0 0.000000 0.0000 0.0000
B 1313 1196.000000 58778.4900 0.0000
P 2324 2137.500000 105253.6700 104986.2100
D 339 249.250000 11318.2600 0.0000
S 113 109.000000 5173.3000 0.0000
H 43 43.500000 3136.3400 0.0000
T 1614 10804.750000 33001.5500 33001.5500
13596 18178.000000 314302.6300 0.0000
Other 199 159.500000 7793.3400 59.2500
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Total 19656 32992.000000 546645.9900 138047.0100