CMS/EIP Fiscal Report Center: 07
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 1646 1502.750000 55827.5500 37.1503
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 80 77.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1592 3037.750000 112872.7500 37.1567
Subtotal (Total Children Is Unduplicated) 1900 4618.250000 168700.3000 36.5291
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 14.4000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.9200 28.9200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 13.8100 13.8100
EXIT-EXIT-EXIT ASSESSMENT 2 2.500000 125.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 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 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 14.000000 777.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 14.000000 777.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 65 130.000000 9700.0000 74.6154
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 22 44.000000 3300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 12.000000 800.0000 66.6667
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 66 132.000000 9900.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 21 42.000000 3150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 114 227.500000 12626.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 76 151.500000 8408.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 65 132.000000 9900.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 32 72.000000 5350.0000 74.3056
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 26.4100 26.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 4.000000 205.6400 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 257.0500 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 4 4.000000 205.6400 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 5 5.000000 250.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 11.000000 533.0100 48.4555
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.8600 44.8600
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 9.000000 476.3700 52.9300
Subtotal (Total Children Is Unduplicated) 347 1041.500000 68622.4300 65.8881
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.000000 672.2200 336.1100
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 38 42.750000 2137.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 56 61.750000 3087.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 2.500000 62.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 190 261.500000 13075.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 104 137.250000 6862.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 101 111.750000 5587.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 60 63.250000 3162.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 37 44.500000 2225.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 28 40.250000 2012.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 95 106.750000 5337.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 40 44.000000 2200.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 5 7.000000 175.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 69 128.500000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 9 24.000000 1200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 340 1556.750000 77837.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 56 124.750000 6237.5000 50.0000
INTR-T1013-INTERPRETER 1 3.000000 154.5000 51.5000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1307 7606.000000 76955.0000 10.1177
OCCT-97530-OT SESSION BY LICENSED OT 36 108.500000 7391.7800 68.1270
OCCT-97530GT-OT SESSION BY LICENSED OT 2 2.000000 143.9200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 41 169.750000 11805.7100 69.5476
PHY-97110GT-PT SESSION BY LICENSED PT 3 4.500000 323.8200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 1 9.000000 518.0400 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 116 513.000000 34174.3000 66.6166
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 143.9200 71.9600
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 1 2.750000 101.7500 37.0000
TRAV-TRAVS-Travel by mile 15 1103.000000 490.6600 0.4448
Subtotal (Total Children Is Unduplicated) 1404 12283.75000 264100.6200 21.5000
-----------------------------------------------------------------------------------------------------------------------
Total 17943.500000 501423.3500 27.9446
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2409
-----------------------------------------------------------------------------------------------------------------------
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 12.250000 455.7000 0.0000
U 0 0.000000 0.0000 0.0000
B 1028 825.750000 36201.7000 0.0000
P 6174 13705.400000 336285.7500 343529.0500
D 11 12.250000 758.1000 0.0000
S 16 14.500000 539.4000 0.0000
H 11 22.000000 1650.0000 0.0000
T 0 0.000000 0.0000 0.0000
5693 3168.100000 118720.1000 120.0000
Other 365 183.250000 6812.6000 0.0000
---------------------------------------------------------
Total 13313 17943.500000 501423.3500 343649.0500