CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 Page: 1
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1783 5083.750000 189087.5000 37.1945
TCM-T1017TL-TARGETED CASE MANAGEMENT 1795 6724.750000 249919.0000 37.1641
Subtotal (Total Children Is Unduplicated) 2020 11808.50000 439006.5000 37.1772
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Screening, Eval, and Assessment,Class #02
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.3200 45.3200
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 231.6200 115.8100
EXIT-EXIT-EXIT ASSESSMENT 216 307.000000 15350.0000 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 7 13.500000 973.5000 72.1111
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 7 12.500000 908.2500 72.6600
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 6 11.500000 862.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 17 29.500000 1588.1100 53.8342
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 224 423.000000 31675.0000 74.8818
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 157 288.500000 21542.5000 74.6707
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 104 198.000000 14850.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 329 602.500000 33338.7500 55.3340
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 83.000000 6225.0000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 2 13.000000 650.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 21 145.000000 7250.0000 50.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 3 3.000000 154.2300 51.4100
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 12 12.000000 615.4800 51.2900
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 205.6400 51.4100
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 687 2164.000000 137472.9500 63.5272
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 692.7800 692.7800
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 113 192.000000 9600.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 39 71.000000 3550.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 103 123.000000 3075.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 12 13.000000 650.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 6 6.000000 300.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 2.000000 50.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 10 11.000000 500.0000 45.4545
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 4 4.000000 200.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 8 9.250000 462.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 19 21.000000 1050.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 7 7.000000 350.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 5 3.500000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 7 40.000000 2000.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1167 8666.750000 431352.2300 49.7709
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 49 157.000000 7850.0000 50.0000
INTR-T1013-INTERPRETER 113 455.000000 22750.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 63 326.000000 3260.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 158 1078.500000 77428.1500 71.7924
OCCT-97530GT-OT SESSION BY LICENSED OT 6 29.250000 2104.8300 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 8 27.000000 1942.9200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 175 1211.500000 86294.6200 71.2296
PHY-97110GT-PT SESSION BY LICENSED PT 10 71.000000 4839.5600 68.1628
SENS-V5050-IN EAR MONAURAL HEARING AID 1 2.000000 456.0000 228.0000
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 369 2928.000000 207136.2700 70.7433
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 20 85.000000 6080.6000 71.5365
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 7 23.000000 1655.0800 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 10.750000 773.5700 71.9600
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.9600 13.9600
TRAV-TRAVS-Travel by mile 1341 132968.0000 58079.3400 0.4368
Subtotal (Total Children Is Unduplicated) 1634 148547.5000 934655.3700 6.2920
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Total 162520.000000 1511134.8200 9.2981
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Number of Children (Unduplicated) With at Least One Service 2162
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Center 09
Flag Claims Units Chgs Paid
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R 7 4.000000 148.8000 0.0000
U 0 0.000000 0.0000 0.0000
B 1726 1924.750000 77599.4700 5074.7600
P 12753 103064.750000 725451.6200 725726.4500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 215 321.500000 17996.6000 0.0000
T 5068 50064.000000 289530.6100 289530.0100
2159 6820.000000 377988.5200 0.0000
Other 168 321.000000 22419.2000 0.0000
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Total 22096 162520.000000 1511134.8200 1020331.2200