CMS/EIP Fiscal Report Center: 10
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 3372 11098.00000 412741.2500 37.1906
Subtotal (Total Children Is Unduplicated) 3372 11098.00000 412741.2500 37.1906
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 29 30.000000 585.3000 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 29 30.000000 440.4000 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 30 31.000000 223.2000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 28 29.000000 838.6800 28.9200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 28 29.000000 610.1600 21.0400
EXIT-EXIT-EXIT ASSESSMENT 17 28.500000 1425.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 11.500000 862.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 10 24.000000 1800.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 7.000000 525.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 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 3 5.500000 412.5000 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 6 12.000000 666.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 200 365.000000 27337.5000 74.8973
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 297 578.500000 43387.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 67 116.500000 8737.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 132 252.000000 18861.0000 74.8452
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 59 111.000000 8325.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 52 101.500000 7612.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 212 400.500000 22227.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 326 629.000000 34958.2500 55.5775
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 93 175.000000 13125.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 61.000000 4575.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 16 16.000000 822.5600 51.4100
OCTH-97165GT-OT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 16 18.000000 822.5600 45.6978
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 4 4.000000 205.6400 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 6 5.500000 282.7550 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 28 26.750000 1375.2075 51.4096
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 16 17.250000 784.0000 45.4493
Subtotal (Total Children Is Unduplicated) 821 3134.500000 203042.1725 64.7766
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 6.000000 4207.7800 701.2967
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 34 34.750000 1737.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 289 266.250000 13312.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 7 4.250000 106.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 58 72.000000 3600.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 140 204.750000 10237.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 10 9.500000 475.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 39 49.500000 2475.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 13 14.750000 737.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 64 94.000000 4700.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 38 46.750000 2337.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 99 136.500000 6825.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.750000 43.7500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 4 11.000000 550.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 792 6453.250000 322612.5000 49.9923
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 672 4184.750000 209237.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1095 11117.00000 111170.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 356 1706.000000 121383.6800 71.1510
OCCT-97530GT-OT SESSION BY LICENSED OT 41 94.750000 6746.2500 71.2005
OCCT-97530HM-OT SESSION BY OT ASST 79 294.000000 15989.2400 54.3852
OCCT-97530HMGT-OT SESSION BY OT ASST 3 5.500000 316.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 430 1712.750000 121018.7300 70.6576
PHY-97110GT-PT SESSION BY LICENSED PT 14 36.500000 2415.9300 66.1899
PHY-97110HM-PT SESSION BY PT ASST 3 4.500000 259.0200 57.5600
SENS-V5264-EARMOLD 1 2.000000 36.2600 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 586 3313.750000 235383.4400 71.0323
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 82 244.500000 17594.2200 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 5.500000 316.8000 57.6000
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 8 6.250000 231.2500 37.0000
Subtotal (Total Children Is Unduplicated) 2043 30132.75000 1216056.9000 40.3567
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Total 44365.250000 1831840.3225 41.2900
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Number of Children (Unduplicated) With at Least One Service 3686
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Center 10
Flag Claims Units Chgs Paid
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R 49 42.250000 1796.1000 0.0000
U 0 0.000000 0.0000 0.0000
B 8558 7520.250000 321693.0500 0.0000
P 6364 18685.000000 546873.9000 545386.3800
D 130 161.750000 9145.3700 0.0000
S 440 311.000000 11695.0200 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
9862 17038.500000 914833.7325 100.0000
Other 640 606.500000 25803.1500 0.0000
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Total 26043 44365.250000 1831840.3225 545486.3800