CMS/EIP Fiscal Report Center: 57
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 2221 18056.61828 670906.5500 37.1557
Subtotal (Total Children Is Unduplicated) 2221 18056.61828 670906.5500 37.1557
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Screening, Eval, and Assessment,Class #02
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 1 1.000000 15.8400 15.8400
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-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 21.0400 21.0400
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 38 65.000000 4875.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 17 31.000000 2325.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 9 15.500000 1162.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 59 109.000000 6049.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 727 1289.000000 96606.7500 74.9471
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 237 415.000000 31080.0000 74.8916
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 214 353.000000 26475.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1023 1861.500000 103313.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 115 202.500000 15187.5000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 205.2800 51.3200
OCTH-97167-OT EVAL HIGH COMPLEXITY 6 6.000000 308.1000 51.3500
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 154.2300 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.5100 51.1700
SPCH-92521-EVAL OF SPEECH FLUENCY 13 13.000000 667.9700 51.3823
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
Subtotal (Total Children Is Unduplicated) 1233 4390.500000 289694.2200 65.9821
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 13.000000 325.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1404 26443.25000 1322162.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 125 877.500000 43875.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 263.032242 18910.9000 71.8957
OCCT-97530HM-OT SESSION BY OT ASST 10 59.000000 3397.6000 57.5864
PHY-97110-PT SESSION BY LICENSED PT 6 102.500000 7367.3200 71.8763
PHY-97110GT-PT SESSION BY LICENSED PT 1 4.500000 322.5200 71.6711
PHY-97110HM-PT SESSION BY PT ASST 13 146.750000 8437.5300 57.4959
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 19 224.000000 16118.0000 71.9554
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 30.000000 1728.0000 57.6000
Subtotal (Total Children Is Unduplicated) 1461 28163.53224 1422644.3700 50.5137
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Total 50610.650522 2383245.1400 47.0898
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Number of Children (Unduplicated) With at Least One Service 2262
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Center 57
Flag Claims Units Chgs Paid
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R 25 44.500000 1954.2000 0.0000
U 0 0.000000 0.0000 0.0000
B 4785 6949.750000 303470.9000 139.5000
P 9987 14794.368280 627590.6000 627065.2260
D 5 8.750000 324.3500 92.5000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 174 265.750000 13268.6500 9085.3500
7661 28172.032242 1422682.5900 1422682.4900
Other 409 375.500000 13953.8500 93.0000
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Total 23046 50610.650522 2383245.1400 2059158.0660