CMS/EIP Fiscal Report Center: 57
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 33 53.500000 1987.5500 37.1505
Subtotal (Total Children Is Unduplicated) 33 53.500000 1987.5500 37.1505
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Screening, Eval, and Assessment,Class #02
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 1 1.000000 15.8400 15.8400
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-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.9200 28.9200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 21.0400 21.0400
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 11.000000 825.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 205.2800 51.3200
OCTH-97167-OT EVAL HIGH COMPLEXITY 6 6.000000 308.1000 51.3500
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 154.2300 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.5100 51.1700
SPCH-92521-EVAL OF SPEECH FLUENCY 13 13.000000 667.9700 51.3823
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
Subtotal (Total Children Is Unduplicated) 48 68.500000 4082.2200 59.5945
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 13.000000 325.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1404 26443.25000 1322162.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 125 877.500000 43875.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 263.032242 18910.9000 71.8957
OCCT-97530HM-OT SESSION BY OT ASST 10 59.000000 3397.6000 57.5864
PHY-97110-PT SESSION BY LICENSED PT 6 102.500000 7367.3200 71.8763
PHY-97110GT-PT SESSION BY LICENSED PT 1 4.500000 322.5200 71.6711
PHY-97110HM-PT SESSION BY PT ASST 13 146.750000 8437.5300 57.4959
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 19 224.000000 16118.0000 71.9554
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 30.000000 1728.0000 57.6000
Subtotal (Total Children Is Unduplicated) 1461 28163.53224 1422644.3700 50.5137
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Total 28285.532242 1428714.1400 50.5104
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Number of Children (Unduplicated) With at Least One Service 1479
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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 88 110.250000 6036.2500 6037.6000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 6 7.000000 323.8000 323.0000
7658 28167.032242 1422307.5900 1422307.4900
Other 1 1.250000 46.5000 93.0000
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Total 7753 28285.532242 1428714.1400 1428761.0900