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
Payclass Filters:GR
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 1876 5288.250000 196694.9000 37.1947
TCM-T1017TL-TARGETED CASE MANAGEMENT 834 3085.500000 114689.5000 37.1705
Subtotal (Total Children Is Unduplicated) 1983 8373.750000 311384.4000 37.1858
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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-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 11.000000 610.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 44 85.500000 6412.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 30 59.000000 4425.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 21 39.500000 2962.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 75 136.500000 7575.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 19.000000 1425.0000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 9.000000 450.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 16 67.000000 3350.0000 50.0000
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 154.2300 51.4100
Subtotal (Total Children Is Unduplicated) 354 757.000000 44257.7400 58.4647
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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 98 158.500000 7925.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 39 71.000000 3550.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 91 104.000000 2600.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 10 11.000000 550.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 5 5.000000 250.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 2.000000 50.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 8 9.000000 400.0000 44.4444
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 4 4.000000 200.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 7 8.250000 412.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 18 20.000000 1000.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 6 6.000000 300.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 5 3.500000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 5 35.000000 1750.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 372 2232.000000 111350.0000 49.8880
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 16 41.000000 2050.0000 50.0000
INTR-T1013-INTERPRETER 125 492.250000 24612.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 62 321.000000 3210.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 66 311.500000 22343.5800 71.7290
OCCT-97530GT-OT SESSION BY LICENSED OT 2 12.000000 863.5200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 55 286.000000 20580.5600 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 3 16.000000 1151.3600 71.9600
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 151 777.500000 55948.9000 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 7 16.000000 1151.3600 71.9600
TRAV-TRAVS-Travel by mile 1223 105432.0000 46008.2500 0.4364
Subtotal (Total Children Is Unduplicated) 1435 110380.5000 309492.3100 2.8039
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Total 119511.250000 665134.4500 5.5655
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Number of Children (Unduplicated) With at Least One Service 2201
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Center 09
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 9496 76536.250000 462824.1900 462814.8900
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 4503 42939.000000 199434.5700 199434.5700
4 7.000000 768.9400 0.0000
Other 15 29.000000 2106.7500 0.0000
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Total 14018 119511.250000 665134.4500 662249.4600