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
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 3345 11246.00000 416083.5000 36.9984
Subtotal (Total Children Is Unduplicated) 3345 11246.00000 416083.5000 36.9984
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 21 22.000000 447.1300 20.3241
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 21 22.000000 320.0500 14.5477
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 21 21.000000 204.8800 9.7562
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 21 21.000000 603.2400 28.7257
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 19 20.000000 398.4200 19.9210
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 13.500000 1012.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 15 27.500000 2023.5000 73.5818
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 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 6 11.500000 638.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 12 20.500000 1137.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 190 374.000000 28050.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 288 562.000000 42150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 58 110.000000 8250.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 64 120.500000 9037.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 32 58.500000 4387.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 66 119.000000 8925.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 192 372.000000 20646.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 266 509.000000 28221.7500 55.4455
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 78 145.000000 10875.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 49 101.500000 7612.5000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 35 36.000000 1786.7500 49.6319
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 3.500000 178.6700 51.0486
PSTH-97162-PT EVAL MODERATE COMPLEXITY 14 14.000000 714.7000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 48 51.250000 2463.1500 48.0615
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 3 3.000000 153.1500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 748 2788.250000 182283.2400 65.3755
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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 773 7334.750000 366737.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 616 3943.000000 197150.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1078 12629.00000 126290.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 342 2008.000000 141753.3600 70.5943
OCCT-97530GT-OT SESSION BY LICENSED OT 19 101.000000 7215.4400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 90 488.750000 27990.0600 57.2687
OCCT-97530HMGT-OT SESSION BY OT ASST 2 3.500000 200.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 474 2549.000000 179650.8700 70.4790
PHY-97110GT-PT SESSION BY LICENSED PT 36 108.750000 7644.0800 70.2904
PHY-97110HM-PT SESSION BY PT ASST 11 20.000000 1143.2000 57.1600
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 507 2932.750000 207342.6600 70.6991
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 77 289.000000 20574.7200 71.1928
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 44.500000 2545.4000 57.2000
SPL-92508HA-GROUP SPL SESSION PER CHILD 2 4.000000 55.5200 13.8800
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 9 9.500000 351.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1957 33355.50000 1331297.7600 39.9124
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Total 47389.750000 1929664.5000 40.7190
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Number of Children (Unduplicated) With at Least One Service 3668
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Center 10
Flag Claims Units Chgs Paid
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R 74 56.250000 2081.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 9029 7875.750000 327143.5000 0.0000
P 6910 20187.750000 562558.9100 557370.2600
D 34 31.500000 1670.6500 0.0000
S 64 101.500000 3083.7300 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
10028 18804.250000 1019860.9600 0.0000
Other 435 332.750000 13265.5000 0.0000
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Total 26574 47389.750000 1929664.5000 557370.2600