CMS/EIP Fiscal Report Center: 10
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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 3609 12285.25000 456862.5000 37.1879
Subtotal (Total Children Is Unduplicated) 3609 12285.25000 456862.5000 37.1879
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 39 39.000000 760.8900 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 39 39.000000 572.5200 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 40 40.000000 288.0000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 39 39.000000 1127.8800 28.9200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 40 40.000000 841.6000 21.0400
EXIT-EXIT-EXIT ASSESSMENT 2 3.500000 175.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 22.500000 1687.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 13 23.000000 1725.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 8 16.000000 1200.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.500000 187.5000 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 4 8.000000 600.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 5 9.000000 675.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 20.000000 1110.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 13 24.500000 1359.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 189 357.500000 26775.0000 74.8951
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 278 542.500000 40648.5000 74.9281
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 62 117.500000 8812.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 115 217.000000 16275.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 78 133.500000 10012.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 52 92.000000 6900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 227 419.500000 23226.7500 55.3677
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 341 655.500000 36380.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 119 204.000000 15262.5000 74.8162
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 32 62.500000 4687.5000 75.0000
NURS-T1001-NURSING ASSESSMENT 1 2.000000 100.0000 50.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 22 20.000000 982.4800 49.1240
OCTH-97166-OT EVAL MODERATE COMPLEXITY 25 25.000000 1285.2500 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 13 12.500000 591.2150 47.2972
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 51 54.250000 2742.8975 50.5603
SPCH-92521GT-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 462.6900 51.4100
Subtotal (Total Children Is Unduplicated) 878 3261.250000 208162.7225 63.8291
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 11 22.000000 11631.7400 528.7155
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 36 33.000000 1650.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 266 237.250000 11862.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 25 22.250000 556.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 62 81.750000 4087.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 171 216.500000 10825.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 5 3.750000 93.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 33 67.000000 3350.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 3.000000 150.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 84 127.000000 6350.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 30 38.000000 1900.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 118 168.000000 8400.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.250000 6.2500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 7 21.000000 1050.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 899 7332.750000 366637.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 646 3792.250000 189465.5000 49.9612
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1253 12617.00000 126170.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 358 1849.500000 131381.5600 71.0363
OCCT-97530GT-OT SESSION BY LICENSED OT 43 128.000000 9210.8800 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 76 356.250000 20224.5600 56.7707
OCCT-97530HMGT-OT SESSION BY OT ASST 5 11.250000 648.0000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 433 1795.250000 127464.4600 71.0010
PHY-97110GT-PT SESSION BY LICENSED PT 17 46.000000 3310.1600 71.9600
PHY-97110HM-PT SESSION BY PT ASST 3 3.750000 201.5200 53.7387
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 2.000000 115.1200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 606 3633.750000 257310.3500 70.8112
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 70 293.250000 21102.2700 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 3.750000 216.0000 57.6000
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 1 9.750000 561.6000 57.6000
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 2 1.250000 46.2500 37.0000
Subtotal (Total Children Is Unduplicated) 2122 32919.50000 1316103.7200 39.9795
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Total 48466.000000 1981128.9425 40.8767
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Number of Children (Unduplicated) With at Least One Service 3876
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Center 10
Flag Claims Units Chgs Paid
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R 8 6.750000 251.1000 0.0000
U 0 0.000000 0.0000 0.0000
B 10149 8829.250000 370133.7000 0.0000
P 7239 20948.500000 616101.4300 615781.7100
D 200 239.750000 13749.0400 0.0000
S 80 101.000000 2532.6900 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
10777 18039.500000 967154.4825 40.0000
Other 401 301.250000 11206.5000 0.0000
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Total 28854 48466.000000 1981128.9425 615821.7100