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
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 760 664.250000 24710.1000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1607 6844.500000 254563.9000 37.1925
Subtotal (Total Children Is Unduplicated) 1668 7508.750000 279274.0000 37.1931
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Screening, Eval, and Assessment,Class #02
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 1 1.000000 13.8000 13.8000
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-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 57.8400 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
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 21.0400 21.0400
EXIT-EXIT-EXIT ASSESSMENT 8 21.000000 1050.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 13 22.000000 1650.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 7 13.000000 975.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 22 41.500000 2303.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 320 570.500000 42758.2500 74.9487
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 78 139.500000 10462.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 78 133.000000 9975.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 428 785.500000 43595.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 68.000000 5100.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 6 6.000000 308.4600 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 17 17.000000 873.9700 51.4100
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 18 18.000000 925.3800 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 359.8700 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 6.000000 342.5600 57.0933
Subtotal (Total Children Is Unduplicated) 542 1868.000000 121507.9000 65.0471
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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 62 62.250000 3112.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 5.000000 250.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 7 8.000000 400.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 43 45.250000 2262.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 89 91.000000 4550.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 13 279.000000 6975.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 6 34.000000 1700.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 999 6565.250000 328262.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 72 214.000000 10700.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1021 7602.000000 76020.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 56 298.458459 21392.0700 71.6752
OCCT-97530HM-OT SESSION BY OT ASST 10 26.500000 1526.4000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 19 83.000002 5972.6800 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 2 1.500000 107.9400 71.9600
PHY-97110HM-PT SESSION BY PT ASST 17 64.500000 3712.6200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 90 550.500445 39613.9800 71.9599
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 11.500000 827.5400 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 15 53.000000 3052.8000 57.6000
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 1 2.000000 115.2000 57.6000
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) 1095 17947.70891 514828.1900 28.6849
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Total 27324.458906 915610.0900 33.5088
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Number of Children (Unduplicated) With at Least One Service 1848
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Center 57
Flag Claims Units Chgs Paid
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R 148 213.750000 7951.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2057 3058.500000 131236.5000 0.0000
P 944 1459.787128 67169.0700 67431.3560
D 0 0.000000 0.0000 0.0000
S 23 63.500000 1741.7600 1741.7600
H 10 10.000000 219.9500 219.9500
T 3301 12497.957490 240794.6300 240677.9900
5312 9609.535159 451990.2100 272605.1100
Other 315 411.429129 14506.4700 3905.1200
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Total 12110 27324.458906 915610.0900 586581.2860