CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 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 294 187.250000 6965.7000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 77 78.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 305 349.000000 12982.8000 37.2000
Subtotal (Total Children Is Unduplicated) 402 614.250000 19948.5000 32.4762
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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-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 13.8100 13.8100
EXIT-EXIT-COS Exit 12 11.500000 575.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 29.500000 2212.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 17.500000 1312.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 48.500000 2691.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 6 12.000000 666.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 10.500000 787.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 16.000000 1200.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 257.0500 51.4100
Subtotal (Total Children Is Unduplicated) 84 181.000000 11625.1800 64.2275
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 1214.2800 607.1400
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 27 33.750000 1687.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 28 33.500000 1675.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.500000 37.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 62 77.500000 3875.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 39 37.750000 1887.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 25 25.000000 1250.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 17 16.500000 825.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 4 4.000000 200.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 33 27.250000 1362.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 112 576.750000 28837.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 49 119.000000 5950.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 241 1586.000000 23790.0000 15.0000
INTR-T1013-INTERPRETER 21 79.000000 3950.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 162 856.000000 10272.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 35 116.250000 8228.6900 70.7844
OCCT-97530GT-OT SESSION BY LICENSED OT 8 25.000000 1799.0000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 13 79.250000 5702.8300 71.9600
SENS-V5264-EARMOLD 1 2.000000 36.2600 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 45 219.750000 15553.8100 70.7796
TRAV-TRAVS-Travel by mile 169 10134.00000 4508.9000 0.4449
Subtotal (Total Children Is Unduplicated) 475 14051.75000 122643.2700 8.7280
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Total 14847.000000 154216.9500 10.3871
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Number of Children (Unduplicated) With at Least One Service 688
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Center 02
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 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3844 10971.000000 107910.9900 107672.2200
604 1114.250000 15988.1100 150.0000
Other 1311 2761.750000 30317.8500 178.9700
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Total 5759 14847.000000 154216.9500 108001.1900