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
Payclass Filters:GR
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 1161 3985.750000 148265.7500 37.1990
Subtotal (Total Children Is Unduplicated) 1161 3985.750000 148265.7500 37.1990
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.000000 39.0200 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 29.3600 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 14.4000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 57.8400 28.9200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 21.0400 21.0400
EXIT-EXIT-EXIT ASSESSMENT 17 28.500000 1425.0000 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 3 8.000000 600.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 34.500000 2587.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 65 127.000000 9525.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 8.500000 637.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 12 23.500000 1762.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 10 19.000000 1425.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 40.000000 2220.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 72 140.000000 7770.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 13.500000 1012.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 205.6400 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166GT-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 3 3.250000 167.0800 51.4092
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 0.250000 12.8500 51.4000
Subtotal (Total Children Is Unduplicated) 140 483.500000 31255.3700 64.6440
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 1619.8600 809.9300
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 303 2470.000000 123500.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 221 1266.750000 63337.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1095 11117.00000 111170.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 35 216.500000 15579.3400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 5 22.500000 1619.1000 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 6 15.250000 878.4000 57.6000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 54 213.000000 15213.3200 71.4240
PHY-97110GT-PT SESSION BY LICENSED PT 3 5.500000 395.7800 71.9600
SENS-V5264-EARMOLD 1 2.000000 36.2600 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 118 703.500000 50552.4200 71.8585
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 35 90.000000 6476.4000 71.9600
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 8 6.250000 231.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1451 17077.00000 437804.7300 25.6371
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Total 21546.250000 617325.8500 28.6512
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Number of Children (Unduplicated) With at Least One Service 2126
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Center 10
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 5351 17038.500000 436550.5600 436550.5600
D 13 14.500000 441.8600 0.0000
S 35 44.250000 1530.2800 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5079 4446.250000 178700.8500 100.0000
Other 4 2.750000 102.3000 0.0000
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Total 10482 21546.250000 617325.8500 436650.5600