CMS/EIP Fiscal Report Center: 02
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 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 2 2.000000 231.6200 115.8100
EXIT-EXIT-EXIT ASSESSMENT 47 55.500000 2775.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 11.500000 862.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 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 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 53 102.500000 7687.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 20 39.000000 2925.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 24.000000 1800.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 36.000000 1998.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 29.000000 2175.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 37.1500 37.1500
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 5 5.000000 257.0500 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 5 5.000000 257.0500 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 5 7.000000 248.6400 35.5200
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 5 5.000000 225.7400 45.1480
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 113.9800 37.9933
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 4.000000 165.3900 41.3475
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 20 20.000000 1027.1200 51.3560
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 3 17.000000 854.8500 50.2853
Subtotal (Total Children Is Unduplicated) 185 412.500000 26315.0400 63.7940
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 10 20.000000 31967.9100 1598.3955
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 77 97.000000 4850.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 30 41.750000 2087.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 3.750000 93.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 181 278.000000 13875.2500 49.9110
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 98 96.000000 4760.0000 49.5833
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.750000 18.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 72 85.750000 4287.5000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 74 75.000000 3750.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 6.000000 300.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 4 3.000000 150.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 2.250000 56.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 45 41.750000 2087.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 48 41.000000 2050.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 11 16.000000 800.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 135 2139.750000 106987.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 36 256.250000 12812.5000 50.0000
INTR-T1013-INTERPRETER 48 342.250000 17087.5000 49.9270
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 582 9029.000000 90414.0000 10.0137
OCCT-97530-OT SESSION BY LICENSED OT 54 601.500000 41465.3800 68.9366
OCCT-97530GT-OT SESSION BY LICENSED OT 9 90.750000 6528.2900 71.9371
PHY-97110-PT SESSION BY LICENSED PT 39 401.500000 24417.5500 60.8158
PHY-97110GT-PT SESSION BY LICENSED PT 4 22.250000 1316.0200 59.1470
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 459.2200 459.2200
SENS-V5264-EARMOLD 2 3.000000 54.3900 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 83 824.500000 57081.2600 69.2314
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 18.500000 1325.6700 71.6578
TRAV-TRAVS-Travel by mile 370 43240.00000 19225.9100 0.4446
Subtotal (Total Children Is Unduplicated) 758 57779.25000 450334.6000 7.7941
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Total 58191.750000 476649.6400 8.1910
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Number of Children (Unduplicated) With at Least One Service 778
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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 3 3.000000 99.4600 -116.4200
H 0 0.000000 0.0000 0.0000
T 16116 55211.500000 447330.8000 447637.0130
1151 2977.250000 29219.3800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 17270 58191.750000 476649.6400 447520.5930