CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Program Patients
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 8 8.000000 143.3600 17.9200
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 8 8.000000 100.8800 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 8.000000 66.0800 8.2600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 8 8.000000 202.4800 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 6 6.000000 111.3000 18.5500
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 20.6800 20.6800
AUDE-V5010-ASSESSMENT FOR HEARING AID 3 3.000000 135.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 3 5.000000 575.0000 115.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 12.500000 937.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 109 233.500000 17512.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 30 64.000000 4800.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 31.500000 2362.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 106 216.000000 11988.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 69.000000 5175.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 2.000000 51.0500 25.5250
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 3.000000 102.1000 34.0333
Subtotal (Total Children Is Unduplicated) 162 700.500000 45642.6300 65.1572
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 26.000000 1300.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 27 173.750000 10964.1000 63.1027
PHY-97110-PT SESSION BY LICENSED PT 42 328.000000 21757.7200 66.3345
PHY-97110HM-PT SESSION BY PT ASST 1 2.000000 114.3200 57.1600
SENS-V5050-IN EAR MONAURAL HEARING AID 3 5.000000 1140.0000 228.0000
SENS-V5264-EARMOLD 3 5.000000 90.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 155.000000 10607.7500 68.4371
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.000000 27.7600 13.8800
Subtotal (Total Children Is Unduplicated) 71 696.750000 46001.6500 66.0232
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Total 1397.250000 91644.2800 65.5890
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Number of Children (Unduplicated) With at Least One Service 223
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Center 10
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 205 375.000000 22719.9900 22719.9900
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 0 0.000000 0.0000 0.0000
465 1022.250000 68924.2900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 670 1397.250000 91644.2800 22719.9900