CMS/EIP Fiscal Report Center: 57
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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-92550-TYMPANOMETRY & REFLEX THRESH 2 2.000000 27.6000 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-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 42.0800 21.0400
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 9 9.000000 462.6900 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 15 13.832912 711.1500 51.4100
SPCH-92521GT-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 10.000000 514.1000 51.4100
Subtotal (Total Children Is Unduplicated) 35 47.832912 2140.8900 44.7577
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EI Services,Class #03
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 231.6200 231.6200
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 73 75.000000 3750.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 57 57.000000 2850.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 2.000000 50.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 4.000000 200.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 11 11.000000 550.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 40 40.000000 2000.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 82 84.000000 4200.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 18.000000 450.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 7 42.000000 2100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 353 2501.000000 125050.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 29 123.500000 6175.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1097 9057.000000 90570.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 104.554475 7523.7400 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 5 25.000000 1440.0000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 3 16.613118 1195.4800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 1 0.000000 0.0000 0.0000
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 459.2200 459.2200
SENS-V5264-EARMOLD 1 1.000000 18.1300 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 39 236.237912 16999.6800 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 20.000000 1439.2000 71.9600
TRAV-TRAVS-Travel by mile 7 2648.000000 1178.3500 0.4450
Subtotal (Total Children Is Unduplicated) 1121 15068.90551 268480.4200 17.8168
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Total 15116.738417 270621.3100 17.9021
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Number of Children (Unduplicated) With at Least One Service 1126
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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 2 8.000000 80.0000 80.0000
D 0 0.000000 0.0000 0.0000
S 13 17.000000 503.0100 503.0100
H 13 13.000000 904.8700 904.8700
T 3759 15055.738417 268592.0200 268483.7800
1 18.000000 450.0000 450.0000
Other 3 5.000000 91.4100 91.4100
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Total 3791 15116.738417 270621.3100 270513.0700