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
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 294 187.250000 6965.7000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 77 78.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 75 85.250000 3171.3000 37.2000
Subtotal (Total Children Is Unduplicated) 330 350.500000 10137.0000 28.9215
-----------------------------------------------------------------------------------------------------------------------
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-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 10 18.500000 1387.5000 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 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 16.500000 915.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 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 7 14.000000 1050.0000 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 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
Subtotal (Total Children Is Unduplicated) 50 106.000000 6898.1300 65.0767
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 20.0000 20.0000
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 102 553.000000 27650.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 39 107.000000 5350.0000 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 12 35.750000 2513.5300 70.3085
OCCT-97530GT-OT SESSION BY LICENSED OT 3 9.000000 647.6400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 6 29.500000 2122.8200 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 23.500000 1678.0900 71.4081
TRAV-TRAVS-Travel by mile 169 10134.00000 4508.9000 0.4449
Subtotal (Total Children Is Unduplicated) 457 13670.50000 95302.9800 6.9714
-----------------------------------------------------------------------------------------------------------------------
Total 14127.000000 112338.1100 7.9520
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 629
-----------------------------------------------------------------------------------------------------------------------
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 3370 10643.750000 83941.4600 83759.9500
558 1086.250000 13973.2300 150.0000
Other 827 2397.000000 14423.4200 125.0000
---------------------------------------------------------
Total 4755 14127.000000 112338.1100 84034.9500