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
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 2234 3015.000000 112045.4000 37.1627
TCM-T1017TL-TARGETED CASE MANAGEMENT 3469 29263.72715 1087262.0500 37.1539
Subtotal (Total Children Is Unduplicated) 3502 32278.72715 1199307.4500 37.1547
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Screening, Eval, and Assessment,Class #02
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 8 8.000000 114.4800 14.3100
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 11 11.000000 218.6000 19.8727
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 13 13.000000 190.7400 14.6723
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 31.3900 7.8475
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 13 13.000000 375.7600 28.9046
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 45.0800 45.0800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 27.6200 13.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 9 9.000000 189.2100 21.0233
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 33 74.000000 3700.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 79 141.500000 10572.4300 74.7168
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 29 54.000000 4050.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 13 21.500000 1612.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 6 11.500000 862.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 110 206.500000 11460.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1250 2227.500000 165796.1900 74.4315
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 359 635.500000 47276.1500 74.3921
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 354 589.500000 43582.2900 73.9309
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1715 3130.500000 172823.2500 55.2063
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 175 310.500000 23016.5900 74.1275
OCTF-97168-OT RE-EVAL EST PLAN CARE 27 28.167089 1438.4000 51.0667
OCTH-97165-OT EVAL LOW COMPLEXITY 22 22.000000 1128.5000 51.2955
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 83 83.993004 4312.6800 51.3457
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 8 8.000000 410.5600 51.3200
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 6 5.000000 256.6900 51.3380
PSTH-97163-PT EVAL HIGH COMPLEXITY 16 16.000000 820.0400 51.2525
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 2.000000 102.4600 51.2300
SPCH-92521-EVAL OF SPEECH FLUENCY 116 129.000002 6626.4900 51.3681
SPCH-92521GT-EVAL OF SPEECH FLUENCY 4 4.000000 205.6400 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 84 89.000001 4567.2100 51.3170
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 205.6400 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.8600 44.8600
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 29.000002 1556.7100 53.6797
Subtotal (Total Children Is Unduplicated) 2173 7898.160098 508441.6500 64.3747
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EI Services,Class #03
AUDE-V5160-DISPENSING FEE BINAURAL 1 2.000000 463.2400 231.6200
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 8.250000 412.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 241 340.000000 17000.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 328 451.500000 22575.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 2.000000 50.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 14 15.000000 750.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 36 48.000000 2400.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 145 192.250000 9612.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 416 560.750000 28037.5000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 17 1255.000000 31375.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 18 172.000000 8600.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2105 39972.75000 1998637.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 193 1405.500000 70275.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2134 46177.00000 464910.0000 10.0680
OCCT-97530-OT SESSION BY LICENSED OT 109 1477.585403 105581.0894 71.4552
OCCT-97530GT-OT SESSION BY LICENSED OT 1 5.000000 357.2000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 42 312.111116 17974.0000 57.5885
PHY-97110-PT SESSION BY LICENSED PT 32 354.500002 25480.1800 71.8764
PHY-97110GT-PT SESSION BY LICENSED PT 6 17.500000 1255.9200 71.7669
PHY-97110HM-PT SESSION BY PT ASST 28 307.500005 17681.7000 57.5015
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 2.000000 918.4400 459.2200
SENS-V5264-EARMOLD 1 3.000000 54.3900 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 161 2791.780500 200720.9200 71.8971
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 16 153.000000 11003.3800 71.9175
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 29 121.235670 6971.4400 57.5032
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 5 9.952431 573.2600 57.6000
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 4 6.250000 231.2500 37.0000
TRAV-TRAVS-Travel by mile 21 11336.00000 5044.3800 0.4450
Subtotal (Total Children Is Unduplicated) 2234 107499.4151 3048945.7894 28.3624
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Total 147676.302377 4756694.8894 32.2103
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Number of Children (Unduplicated) With at Least One Service 3526
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Center 57
Flag Claims Units Chgs Paid
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R 25 44.500000 1954.2000 0.0000
U 0 0.000000 0.0000 0.0000
B 4786 6951.750000 303620.9000 139.5000
P 10305 15191.170487 654406.0900 659216.8260
D 193 340.750000 21800.2500 92.5000
S 74 156.580752 4432.3400 4412.3100
H 54 55.000000 2378.1700 2378.1700
T 20334 76438.595952 1506387.1194 1499053.8400
23693 47575.699330 2233429.5000 1539325.6500
Other 723 922.255856 28286.3200 14369.6700
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Total 60187 147676.302377 4756694.8894 3718988.4660