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
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 2159 2505.750000 93059.4500 37.1384
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 380 313.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1859 8646.250000 320966.2000 37.1220
Subtotal (Total Children Is Unduplicated) 3041 11465.75000 414025.6500 36.1098
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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 1 1.000000 56.1000 56.1000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.000000 87.9800 14.6633
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 22.0700 22.0700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 6.000000 45.7900 7.6317
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 6.000000 173.3200 28.8867
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 45.0800 45.0800
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 21.0400 21.0400
AUDE-V5010-ASSESSMENT FOR HEARING AID 3 3.000000 135.9600 45.3200
EXIT-EXIT-EXIT ASSESSMENT 3 3.000000 150.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.000000 525.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 11 22.000000 1650.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 7 14.000000 1050.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 6.500000 487.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 14 27.000000 1498.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 17.000000 1275.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 21 41.500000 3112.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 29.500000 2137.5000 72.4576
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 81 161.000000 12075.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 31.000000 2325.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 44 84.000000 6300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 56.500000 3135.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 131 256.500000 14235.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 57.000000 4275.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 47 92.000000 6900.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 340 1025.500000 66737.7500 65.0783
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 59 149.000000 15740.8300 105.6432
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 5562.750000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 111 932.500000 46325.0000 49.6783
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 87 440.500000 22025.0000 50.0000
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 34 201.500000 14468.7400 71.8052
OCCT-97530GT-OT SESSION BY LICENSED OT 20 59.500000 4276.5500 71.8748
OCCT-97530TL-OT SESSION BY LICENSED OT 4 9.000000 642.9600 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 2 2.000000 143.4000 71.7000
PHY-97110-PT SESSION BY LICENSED PT 37 322.540000 23182.1600 71.8738
PHY-97110GT-PT SESSION BY LICENSED PT 14 41.250000 2966.4000 71.9127
PHY-97110TL-PT SESSION BY LICENSED PT 1 4.000000 287.3200 71.8300
SENS-V5264-EARMOLD 3 4.000000 72.3900 18.0975
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 44 532.750000 38274.0400 71.8424
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 16 58.000000 4167.5700 71.8547
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 6 29.000000 2081.6400 71.7807
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 5 11.500000 824.6800 71.7113
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) 1706 147641.7900 567742.5500 3.8454
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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
Payclass Filters:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Total 160133.040000 1048505.9500 6.5477
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Number of Children (Unduplicated) With at Least One Service 3273
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Center 54
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 899 655.540000 29876.1700 0.0000
S 9 8.000000 52.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 15948 111649.500000 256437.2600 255416.2700
40938 47680.500000 756958.7700 0.0000
Other 204 139.000000 5162.6500 0.0000
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Total 57998 160132.540000 1048487.3500 255416.2700