CMS/EIP Fiscal Report Center: 54
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 Page: 1
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1953 2344.250000 87059.0500 37.1373
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 297 253.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 3039 20235.75000 751410.5500 37.1328
Subtotal (Total Children Is Unduplicated) 3077 22833.25000 838469.6000 36.7214
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 65 74.000000 3589.0000 48.5000
AUD-92626-EVAL OF AUD REHAB STATUS 2 2.000000 112.2000 56.1000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.5100 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 14 14.000000 205.3200 14.6657
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 2 2.000000 44.1400 22.0700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 15 16.000000 125.5600 7.8475
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 13 14.000000 404.0800 28.8629
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 2 2.000000 90.1600 45.0800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 41.2300 13.7433
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 42.0800 21.0400
AUDE-V5010-ASSESSMENT FOR HEARING AID 4 5.000000 226.6000 45.3200
EXIT-EXIT-EXIT ASSESSMENT 3 3.000000 150.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 12.000000 900.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 30 56.500000 4200.0000 74.3363
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 35 66.500000 4987.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 13.000000 975.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 20 39.500000 2962.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 11 20.500000 1537.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 8 15.000000 1125.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 18 35.000000 1942.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 55 113.000000 6271.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 50 86.000000 6449.7500 74.9971
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 187 376.500000 28125.0000 74.7012
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 65 117.500000 8700.0000 74.0426
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 291 555.500000 41662.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 74 132.000000 9900.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 166 318.000000 23850.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 118 219.500000 12182.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 497 972.500000 53973.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 87 171.500000 12862.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 232 466.000000 34950.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1043 3930.000000 262983.5400 66.9169
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 82 222.000000 24833.9000 111.8644
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 224 212.000000 10600.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 483 648.000000 32400.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 0.500000 12.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 146 162.750000 8125.0000 49.9232
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 719 538.250000 26887.5000 49.9536
CONIP-CONIP-CONSULT, ITDS PHONE 3 1.500000 37.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 102 121.000000 6050.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 886 603.250000 30100.0000 49.8964
CONOP-CONOP-CONSULT, OT, PHONE 4 2.500000 62.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 117 171.250000 8562.5000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 652 357.000000 17825.0000 49.9300
CONPP-CONPP-CONSULT, PT, PHONE 1 0.250000 6.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 177 279.250000 13962.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 566 373.500000 18650.0000 49.9331
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 879 5459.750000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 5 5.000000 212.5000 42.5000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 840 8074.000000 403286.0000 49.9487
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 721 3799.250000 189891.0000 49.9812
INTR-T1013-INTERPRETER 16 136.750000 6176.2500 45.1645
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1387 14763.00000 147630.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 98 692.500000 50599.7100 73.0682
OCCT-97530GT-OT SESSION BY LICENSED OT 60 219.250000 16228.7000 74.0192
OCCT-97530TL-OT SESSION BY LICENSED OT 109 912.500000 65432.5600 71.7069
OCCT-97530TLGT-OT SESSION BY LICENSED OT 70 262.250000 18838.8800 71.8356
PHY-97110-PT SESSION BY LICENSED PT 116 1015.000000 74478.9600 73.3783
PHY-97110GT-PT SESSION BY LICENSED PT 42 107.000000 7686.4600 71.8361
PHY-97110TL-PT SESSION BY LICENSED PT 99 888.750000 63835.8900 71.8266
PHY-97110TLGT-PT SESSION BY LICENSED PT 43 95.250000 6836.2500 71.7717
SENS-V5264-EARMOLD 6 13.000000 235.5600 18.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 152 1507.930000 108430.2500 71.9067
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 60 140.250000 10077.1800 71.8516
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 74 537.250000 38597.0700 71.8419
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 42 164.250000 11799.4100 71.8381
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.9600 13.9600
CMS/EIP Fiscal Report Center: 54
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 Page: 2
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 177 250.500000 9268.5000 37.0000
TRAV-TRAVS-Travel by mile 844 119693.0000 53229.1100 0.4447
Subtotal (Total Children Is Unduplicated) 1681 162431.4300 1480924.3500 9.1172
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Total 189194.680000 2582377.4900 13.6493
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Number of Children (Unduplicated) With at Least One Service 3079
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Center 54
Flag Claims Units Chgs Paid
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R 12 14.000000 520.8000 0.0000
U 0 0.000000 0.0000 0.0000
B 2268 2096.000000 99920.9600 0.0000
P 18847 16864.450000 784883.7000 784339.7400
D 1520 1319.870000 71888.7300 0.0000
S 40 36.610000 1812.6700 37.2000
H 471 520.310000 37330.6500 0.0000
T 17114 112325.980000 326648.5900 325498.8700
48426 55550.770000 1236546.0100 0.0000
Other 570 466.190000 22806.7800 1550.8300
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Total 89268 189194.180000 2582358.8900 1111426.6400