CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2023 ending 06/30/2024 Date of Report:04/12/2025 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 2771 6773.750000 251751.9000 37.1658
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 132 101.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1671 4902.250000 182280.0000 37.1829
Subtotal (Total Children Is Unduplicated) 3013 11777.50000 434031.9000 36.8526
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 5 4.000000 194.0000 48.5000
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 2 2.000000 31.6800 15.8400
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 5.000000 44.0500 8.8100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 8 10.000000 280.2000 28.0200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 27.6200 13.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 42.0800 21.0400
EXIT-EXIT-COS Exit 8 10.000000 500.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 10 18.500000 1026.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 26.500000 1987.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 43 71.500000 5512.5000 77.0979
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 18.000000 1350.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 44 78.000000 5850.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 21 34.000000 2520.7500 74.1397
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 18.500000 1026.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 140 242.000000 13431.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 26.000000 1950.0000 75.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 2.000000 102.8200 51.4100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 0.420000 21.4000 50.9524
Subtotal (Total Children Is Unduplicated) 237 600.920000 38186.6000 63.5469
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 10 14.000000 1450.4700 103.6050
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 55 43.000000 2150.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 68 69.250000 3496.9600 50.4976
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 39 33.500000 1675.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 366 383.000000 19187.5000 50.0979
CONIP-CONIP-CONSULT, ITDS PHONE 8 7.750000 193.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 126 231.500000 11537.5000 49.8380
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 267 347.000000 17350.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 8 5.000000 125.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 94 228.000000 11400.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 462 345.000000 17262.5000 50.0362
CONPP-CONPP-CONSULT, PT, PHONE 50 25.000000 631.2500 25.2500
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 166 260.000000 13000.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 475 484.500000 24212.5000 49.9742
CONSP-CONSP-CONSULT, SLP, PHONE 50 40.750000 1043.7500 25.6135
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 845 5388.500000 0.0000 0.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 175 1583.250000 78862.5000 49.8105
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 83 231.250000 11562.5000 50.0000
EPIC-99601-Early Steps Professional Development Fee 1066 11784.00000 176757.0000 14.9997
INTR-T1013-INTERPRETER 8 11.000000 449.7100 40.8827
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 502 3289.000000 39468.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 141.543090 10185.4400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 4 4.500000 323.8200 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 12 52.500000 3777.9000 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 3 2.500000 179.9000 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 5 16.000000 1151.3600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 28 220.750000 15885.1700 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 8 10.000000 719.6000 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 13 65.000000 4677.4000 71.9600
TRAV-TRAVS-Travel by mile 658 103178.0000 45898.7200 0.4448
Subtotal (Total Children Is Unduplicated) 1373 128501.0431 514934.1200 4.0072
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Total 140879.463090 987152.6200 7.0071
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Number of Children (Unduplicated) With at Least One Service 3111
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Center 53
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 1 0.250000 9.3000 0.0000
P 0 0.000000 0.0000 0.0000
D 1379 1036.170000 45846.6300 0.0000
S 10 4.750000 211.4600 0.0000
H 1 1.000000 71.9600 0.0000
T 16275 112408.043090 254702.7700 225617.6300
39026 27423.500000 686096.6000 0.0000
Other 7 5.750000 213.9000 0.0000
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Total 56699 140879.463090 987152.6200 225617.6300