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
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 870 778.250000 28932.3000 37.1761
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 212 244.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 709 1417.000000 52712.4000 37.2000
Subtotal (Total Children Is Unduplicated) 974 2440.000000 81644.7000 33.4609
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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 10 9.250000 462.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 114.500000 8587.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 11 21.000000 1575.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 27.000000 2025.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 89 161.500000 8963.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 11 20.500000 1137.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 45 84.500000 6337.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 51.000000 3825.0000 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) 189 524.750000 34858.0200 66.4279
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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 17 20.500000 1025.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 11 12.250000 612.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 3.000000 75.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 73 76.000000 3800.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 51 39.000000 1910.0000 48.9744
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.500000 12.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 35 35.500000 1775.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 17 9.250000 462.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 22 22.000000 1100.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 40 22.750000 1137.5000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 7 9.000000 450.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 109 676.000000 33800.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 37 139.750000 6987.5000 50.0000
INTR-T1013-INTERPRETER 32 140.250000 6987.5000 49.8217
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 265 21908.00000 9736.2100 0.4444
Subtotal (Total Children Is Unduplicated) 511 25870.25000 128780.5500 4.9779
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Total 28835.000000 245283.2700 8.5064
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Number of Children (Unduplicated) With at Least One Service 1066
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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 3527 13568.500000 102048.0500 102079.9960
847 1689.500000 18591.8600 0.0000
Other 5239 13576.000000 124633.3600 0.0000
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Total 9614 28835.000000 245283.2700 102079.9960