CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.5100 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 14.6800 14.6800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.9200 28.9200
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 45.0800 45.0800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 13.8100 13.8100
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 6 6.000000 308.4600 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 257.0500 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 16 24.000000 1098.7900 45.7829
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EI Services,Class #03
CONOF-CONOF-CONSULT, OT, FACE TO FACE 65 68.000000 3400.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 61 60.250000 3012.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 4.000000 200.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 7 7.000000 350.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 43 45.250000 2262.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 88 90.000000 4500.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 5 30.000000 1500.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 332 2143.000000 107150.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 20 54.500000 2725.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1019 7521.000000 75210.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 57.750000 4070.6900 70.4881
PHY-97110-PT SESSION BY LICENSED PT 5 21.500000 1547.1400 71.9600
PHY-97110HM-PT SESSION BY PT ASST 2 3.000000 172.6800 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 128.500000 9246.8600 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 8.000000 575.6800 71.9600
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 1 1.000000 37.0000 37.0000
TRAV-TRAVS-Travel by mile 9 1882.000000 837.4600 0.4450
Subtotal (Total Children Is Unduplicated) 1043 12124.75000 216797.5100 17.8806
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Total 12148.750000 217896.3000 17.9357
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Number of Children (Unduplicated) With at Least One Service 1050
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Center 57
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 12 36.000000 480.0000 480.0000
H 5 5.000000 122.0000 122.0000
T 3108 12088.750000 216816.4600 216816.4600
1 4.000000 287.8400 287.8400
Other 7 15.000000 190.0000 190.0000
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Total 3133 12148.750000 217896.3000 217896.3000