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
Payclass Filters:GR
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 3014.500000 112026.8000 37.1626
TCM-T1017TL-TARGETED CASE MANAGEMENT 1312 11204.75000 416267.7500 37.1510
Subtotal (Total Children Is Unduplicated) 2703 14219.25000 528294.5500 37.1535
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Screening, Eval, and Assessment,Class #02
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 4 4.000000 57.2400 14.3100
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 5 5.000000 97.5500 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.000000 88.0800 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 7.2000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 6.000000 173.5200 28.9200
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 45.0800 45.0800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 13.8100 13.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 4 4.000000 84.1600 21.0400
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 21 40.000000 3000.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 8 15.000000 1125.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 29 56.000000 3108.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 180 320.000000 23950.0000 74.8438
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 39 75.000000 5587.5000 74.5000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 36 59.000000 4425.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 235 429.500000 23787.2500 55.3836
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 27.000000 2025.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 9 8.805485 452.3300 51.3691
OCTH-97165-OT EVAL LOW COMPLEXITY 10 10.000000 513.0200 51.3020
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 36 36.000000 1849.6800 51.3800
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 4 4.000000 205.2800 51.3200
PSTH-97161-PT EVAL LOW COMPLEXITY 4 4.000000 205.2800 51.3200
PSTH-97163-PT EVAL HIGH COMPLEXITY 7 7.000000 358.7900 51.2557
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 2.000000 102.4600 51.2300
SPCH-92521-EVAL OF SPEECH FLUENCY 47 48.832912 2509.0600 51.3805
SPCH-92521GT-EVAL OF SPEECH FLUENCY 3 3.000000 154.2300 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 54 56.000000 2874.2800 51.3264
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 0.866428 45.8600 52.9300
Subtotal (Total Children Is Unduplicated) 415 1313.004825 81098.5300 61.7656
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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 240 338.000000 16900.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 323 445.500000 22275.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 2.000000 50.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 13 14.000000 700.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 36 47.000000 2350.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 144 191.250000 9562.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 414 558.250000 27912.5000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 5.000000 125.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 16 160.000000 8000.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 729 13190.50000 659525.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 67 485.000000 24250.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2127 45862.00000 461760.0000 10.0685
OCCT-97530-OT SESSION BY LICENSED OT 40 409.778494 29379.0000 71.6948
OCCT-97530HM-OT SESSION BY OT ASST 14 91.458334 5265.4000 57.5716
PHY-97110-PT SESSION BY LICENSED PT 16 108.196220 7780.3400 71.9095
PHY-97110GT-PT SESSION BY LICENSED PT 2 4.500000 323.3000 71.8444
PHY-97110HM-PT SESSION BY PT ASST 11 49.500000 2842.2200 57.4186
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 91 960.102144 68984.7900 71.8515
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 10 73.500000 5284.6400 71.8999
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 10 18.000000 1029.5800 57.1989
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 1 2.000000 115.2000 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) 2186 74373.03519 1361538.6700 18.3069
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Total 89905.290017 1970931.7500 21.9223
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Number of Children (Unduplicated) With at Least One Service 3251
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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 1 2.000000 150.0000 0.0000
P 2 8.000000 80.0000 80.0000
D 15 20.000000 854.6500 0.0000
S 54 113.250000 2404.8900 2384.8600
H 26 27.000000 1851.9200 1851.9200
T 19299 74347.310850 1365962.5700 1362812.5900
14493 15290.750000 597667.1900 287.8400
Other 45 96.979167 1960.5300 1904.7300
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Total 33935 89905.290017 1970931.7500 1369321.9400