CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1078 3858.000000 142746.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1078 3858.000000 142746.0000 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.000000 62.2400 20.7467
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.000000 43.7400 14.5800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 29.3700 9.7900
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 86.1600 28.7200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 3.000000 62.6700 20.8900
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 53.000000 3975.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 56 110.500000 8287.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 19.500000 1462.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 15 29.500000 2212.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 9.000000 675.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 13.500000 1012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 48.000000 2664.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 54 106.000000 5883.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 32.000000 2400.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 10.000000 750.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 7 8.000000 408.4000 51.0500
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 123 465.000000 30674.7800 65.9673
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EI Services,Class #03
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 33 38.000000 1900.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 221 191.750000 9587.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 15 12.500000 312.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 63 81.500000 4075.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 178 289.250000 14462.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 3 2.250000 56.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 9 9.000000 450.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 31 61.000000 3050.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.500000 125.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 22 26.000000 1300.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 17 20.000000 1000.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 116 152.250000 7612.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 228 1877.750000 93887.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 241 1621.750000 81087.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1078 12624.00000 126240.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 30 158.750000 11341.0900 71.4399
OCCT-97530GT-OT SESSION BY LICENSED OT 3 17.000000 1214.4800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 0.500000 28.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 32 168.750000 12055.5000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 5.500000 392.9200 71.4400
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 456.0000 456.0000
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 81 466.000000 33141.0400 71.1181
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 23 76.250000 5447.3000 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 9 9.500000 351.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1396 17915.75000 409840.6800 22.8760
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Total 22238.750000 583261.4600 26.2273
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Number of Children (Unduplicated) With at Least One Service 2020
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Center 10
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 0 0.000000 0.0000 0.0000
P 5437 17874.750000 409174.9000 409174.9000
D 2 3.000000 214.3200 0.0000
S 41 66.000000 1393.2400 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4717 4291.000000 172218.0000 0.0000
Other 2 4.000000 261.0000 0.0000
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Total 10199 22238.750000 583261.4600 409174.9000