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
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 1946 3113.750000 115673.5000 37.1493
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 685 890.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1759 4974.500000 184785.9500 37.1466
Subtotal (Total Children Is Unduplicated) 2162 8978.250000 300459.4500 33.4653
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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 2 2.000000 231.6200 115.8100
EXIT-EXIT-EXIT ASSESSMENT 48 56.250000 2812.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 20.500000 1537.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 7 13.500000 1012.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 14.500000 804.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 13.500000 749.2500 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 176 321.000000 24075.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 76 143.000000 10725.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 37.000000 2775.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 322 600.500000 33272.2500 55.4076
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 75 136.000000 7548.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 143 271.000000 20325.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 70 136.000000 10200.0000 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) 623 1861.750000 120962.7900 64.9726
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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 87 109.000000 5450.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 51 73.750000 3687.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 5 4.750000 118.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 213 328.000000 16375.2500 49.9245
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 113 107.500000 5335.0000 49.6279
CONIP-CONIP-CONSULT, ITDS PHONE 3 1.500000 37.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 81 96.250000 4812.5000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 78 79.250000 3962.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 3 2.000000 50.0000 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 99 101.750000 5087.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 101 79.750000 3987.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.500000 12.5000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 19 62.500000 3125.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 210 2664.500000 133225.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 72 489.250000 24462.5000 50.0000
INTR-T1013-INTERPRETER 59 385.000000 19225.0000 49.9351
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 583 9059.000000 90714.0000 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
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 9 6.000000 222.0000 37.0000
TRAV-TRAVS-Travel by mile 687 82258.00000 36567.5100 0.4445
Subtotal (Total Children Is Unduplicated) 1011 97902.50000 521579.4500 5.3275
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Total 108742.500000 943001.6900 8.6719
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Number of Children (Unduplicated) With at Least One Service 2191
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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 16405 63300.750000 464308.5200 464549.8530
1161 3158.250000 29559.1400 0.0000
Other 19207 42280.500000 449034.5700 0.0000
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Total 36776 108742.500000 943001.6900 464433.4330