CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 Page: 1
List order: No List
Agency Filter:EXT
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-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 7.2000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.9200 28.9200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 13.8100 13.8100
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.8100 115.8100
EXIT-EXIT-EXIT ASSESSMENT 9 8.500000 425.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 28.000000 2100.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 20.000000 1500.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 12.000000 900.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 4.000000 211.7200 52.9300
Subtotal (Total Children Is Unduplicated) 50 105.000000 7042.0200 67.0669
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 4.000000 4716.6500 1179.1625
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 16 19.000000 950.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 5 4.000000 200.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 2.000000 50.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 59 63.250000 3162.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 45 35.750000 1747.5000 48.8811
CONOF-CONOF-CONSULT, OT, FACE TO FACE 29 28.500000 1425.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 16 8.500000 425.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 5 3.500000 175.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 19 11.250000 562.5000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 7 9.000000 450.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 72 540.500000 27025.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 19 71.000000 3550.0000 50.0000
INTR-T1013-INTERPRETER 27 114.750000 5712.5000 49.7821
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 321 2307.000000 23070.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 26 153.500000 10917.5600 71.1242
OCCT-97530GT-OT SESSION BY LICENSED OT 4 15.750000 1133.3700 71.9600
PHY-97110-PT SESSION BY LICENSED PT 17 73.750000 5005.8800 67.8763
PHY-97110GT-PT SESSION BY LICENSED PT 1 2.250000 161.9100 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 39 199.250000 13878.9700 69.6561
TRAV-TRAVS-Travel by mile 146 10488.00000 4654.8500 0.4438
Subtotal (Total Children Is Unduplicated) 412 14155.50000 108999.1900 7.7001
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Total 14260.500000 116041.2100 8.1372
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Number of Children (Unduplicated) With at Least One Service 418
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Center 02
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 1 1.000000 10.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3464 12616.000000 97459.8100 97491.7560
843 1643.500000 18571.4000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4308 14260.500000 116041.2100 97491.7560