CMS/EIP Fiscal Report Center: 07
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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 1663 1613.000000 59977.7000 37.1839
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 114 122.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 619 1276.000000 47467.2000 37.2000
Subtotal (Total Children Is Unduplicated) 1762 3011.500000 107444.9000 35.6782
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 9 9.000000 125.8300 13.9811
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 8.000000 57.6000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.000000 202.4400 28.9200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.000000 55.2400 13.8100
AUDE-92652-AEP THRSHLD EST MLT FREQ I&R 1 1.000000 75.1300 75.1300
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 28.9900 28.9900
EXIT-EXIT-EXIT ASSESSMENT 4 4.750000 237.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 311.6700 51.9450
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 26.000000 1815.0000 69.8077
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 18.000000 1350.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 66 131.500000 7298.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 35 70.000000 3885.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 40.000000 3000.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 18.950600 1421.2950 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 140.1200 46.7067
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 154.2300 51.4100
Subtotal (Total Children Is Unduplicated) 150 377.200600 21809.3450 57.8190
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 49 47.000000 2350.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 71 84.000000 4050.0000 48.2143
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 16 14.500000 362.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 221 290.000000 14500.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 89 149.500000 7450.0000 49.8328
CONIP-CONIP-CONSULT, ITDS PHONE 2 1.500000 37.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 117 146.500000 7325.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 48 56.000000 2800.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 6 6.000000 150.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 33 33.250000 1662.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 34 39.750000 1987.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 107 126.750000 6337.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 32 34.500000 1725.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 4 4.000000 100.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 92 122.000000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 4 11.000000 550.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 341 1634.500000 81680.0000 49.9725
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 55 145.000000 7250.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1374 8147.000000 81815.0000 10.0423
OCCT-97530-OT SESSION BY LICENSED OT 12 52.000000 3688.3300 70.9294
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.250000 89.9500 71.9600
PHY-97110-PT SESSION BY LICENSED PT 14 37.000000 2468.4400 66.7146
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 8.2100 8.2100
PHY-97110HM-PT SESSION BY PT ASST 1 23.000000 1323.8800 57.5600
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 144.8400 144.8400
SENS-V5264-EARMOLD 1 2.000000 12.0300 6.0150
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 148.500000 9467.9800 63.7574
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 11.000000 791.5600 71.9600
TRAV-TRAVS-Travel by mile 7 414.000000 184.1600 0.4448
Subtotal (Total Children Is Unduplicated) 1475 11783.50000 240311.8800 20.3939
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Total 15172.200600 369566.1250 24.3581
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Number of Children (Unduplicated) With at Least One Service 2339
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Center 07
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 4553 11763.750000 244836.9300 244836.9300
D 2 1.500000 55.8000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6460 3398.950600 124375.7950 0.0000
Other 14 8.000000 297.6000 0.0000
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Total 11029 15172.200600 369566.1250 244836.9300