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: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 2159 2505.750000 93059.4500 37.1384
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 380 313.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 3526 23797.25000 883664.8000 37.1331
Subtotal (Total Children Is Unduplicated) 3564 26616.75000 976724.2500 36.6958
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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 8 13.500000 1012.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 35 66.000000 4912.5000 74.4318
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 8.000000 600.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 52 97.000000 7275.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 9 15.500000 1162.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 28 55.000000 4125.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 17 32.500000 2437.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 16 31.000000 2325.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 24 46.500000 2580.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 79 158.000000 8769.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 109.000000 8174.7500 74.9977
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 256 498.000000 37237.5000 74.7741
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 86 148.500000 11025.0000 74.2424
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 465 885.000000 66375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 95 164.500000 12300.0000 74.7720
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 274 509.500000 38212.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 167 311.500000 17288.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 744 1429.500000 79337.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 126 247.500000 18437.5000 74.4949
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 335 669.500000 50212.5000 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) 1508 5636.500000 379001.2900 67.2405
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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 225 213.000000 10650.0000 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 721 540.000000 26975.0000 49.9537
CONIP-CONIP-CONSULT, ITDS PHONE 3 1.500000 37.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 103 121.250000 6062.5000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 887 603.750000 30125.0000 49.8965
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 653 357.500000 17850.0000 49.9301
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 567 374.000000 18675.0000 49.9332
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 971 5563.750000 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 722 3813.750000 190616.0000 49.9813
INTR-T1013-INTERPRETER 17 138.750000 6246.2500 45.0180
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1496 14950.00000 149500.0000 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 110 933.500000 66943.2000 71.7121
OCCT-97530TLGT-OT SESSION BY LICENSED OT 72 264.250000 18982.2800 71.8346
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 100 893.750000 64193.0900 71.8244
PHY-97110TLGT-PT SESSION BY LICENSED PT 44 96.000000 6890.0900 71.7718
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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 179 251.750000 9314.7500 37.0000
TRAV-TRAVS-Travel by mile 897 120463.0000 53571.6200 0.4447
Subtotal (Total Children Is Unduplicated) 1794 163543.4300 1486268.1900 9.0879
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Total 195796.680000 2841993.7300 14.5150
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Number of Children (Unduplicated) With at Least One Service 3566
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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 2503 2401.250000 114818.0200 0.0000
P 21015 19430.700000 899159.5200 898207.8800
D 1572 1372.870000 74536.9800 0.0000
S 42 39.860000 1936.7700 37.2000
H 489 552.310000 39730.6500 0.0000
T 17307 113117.980000 339575.1200 338425.4000
50781 58380.270000 1347778.4900 0.0000
Other 591 486.940000 23918.7800 1633.3300
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Total 94312 195796.180000 2841975.1300 1238303.8100