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
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 684 597.000000 22208.4000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 141 160.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 533 959.750000 35702.7000 37.2000
Subtotal (Total Children Is Unduplicated) 766 1717.250000 57911.1000 33.7232
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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 4 7.000000 525.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 55.000000 4125.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 23 46.000000 3450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 66 118.500000 6521.2500 55.0316
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 30 53.000000 2941.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 44 83.500000 6262.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 34.500000 2587.5000 75.0000
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) 156 436.500000 28627.0600 65.5832
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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 13 16.500000 825.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 11 15.000000 750.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 58 57.250000 2862.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 15 12.000000 600.0000 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
CONOP-CONOP-CONSULT, OT, PHONE 2 1.000000 25.0000 25.0000
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 19 15.000000 750.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 17 13.250000 662.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 99 460.000000 23000.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 33 131.250000 6562.5000 50.0000
INTR-T1013-INTERPRETER 22 93.500000 4675.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 285 1698.000000 16980.0000 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
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 3 2.750000 101.7500 37.0000
TRAV-TRAVS-Travel by mile 209 15733.00000 6999.6800 0.4449
Subtotal (Total Children Is Unduplicated) 435 18665.25000 99860.5600 5.3501
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Total 20819.000000 186398.7200 8.9533
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Number of Children (Unduplicated) With at Least One Service 897
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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 2835 11821.500000 81133.5200 81106.1000
463 1436.500000 13175.4800 0.0000
Other 3822 7561.000000 92089.7200 0.0000
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Total 7120 20819.000000 186398.7200 81106.1000