CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 Page: 1
List order: No List
Agency Filter:EXT
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.8100 115.8100
EXIT-EXIT-EXIT ASSESSMENT 6 6.000000 300.0000 50.0000
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 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
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 12 22.500000 1687.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 6 12.000000 900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 105.7900 35.2633
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 20.1000 20.1000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 205.6400 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 5.000000 264.6500 52.9300
Subtotal (Total Children Is Unduplicated) 39 78.500000 5040.3100 64.2078
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 4.000000 7511.1300 1877.7825
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 12 15.500000 775.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 6 5.750000 287.5000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 50 49.250000 2462.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 12 9.000000 450.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.750000 18.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 17 16.500000 825.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 16 10.750000 537.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 3.000000 150.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.500000 75.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 6 4.500000 225.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 13 10.000000 500.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 64 341.000000 17050.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 18 78.000000 3900.0000 50.0000
INTR-T1013-INTERPRETER 20 88.250000 4412.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 284 1691.000000 16910.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 27 136.000000 9628.7700 70.7998
OCCT-97530GT-OT SESSION BY LICENSED OT 3 11.000000 791.5600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 15 60.500000 3320.8300 54.8898
PHY-97110GT-PT SESSION BY LICENSED PT 1 3.000000 215.8800 71.9600
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 459.2200 459.2200
SENS-V5264-EARMOLD 1 2.000000 36.2600 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 33 161.000000 11082.9600 68.8383
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 5.750000 413.7700 71.9600
TRAV-TRAVS-Travel by mile 124 8844.000000 3934.5600 0.4449
Subtotal (Total Children Is Unduplicated) 357 11553.00000 85973.6900 7.4417
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Total 11631.500000 91014.0000 7.8248
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Number of Children (Unduplicated) With at Least One Service 361
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Center 02
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2783 10313.000000 77891.0300 77886.0300
460 1318.500000 13122.9700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3243 11631.500000 91014.0000 77886.0300