CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.8100 115.8100
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 30.500000 2287.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 6 11.500000 862.5000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 105.7900 35.2633
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 20.1000 20.1000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 205.6400 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 5.000000 264.6500 52.9300
Subtotal (Total Children Is Unduplicated) 35 64.500000 4475.9000 69.3938
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 3.000000 7461.1400 2487.0467
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 2.000000 100.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 25 131.000000 9268.9700 70.7555
OCCT-97530GT-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 12 55.250000 3132.2400 56.6921
PHY-97110GT-PT SESSION BY LICENSED PT 1 3.000000 215.8800 71.9600
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 459.2200 459.2200
SENS-V5264-EARMOLD 1 2.000000 36.2600 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 32 150.000000 10291.4000 68.6093
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 5.750000 413.7700 71.9600
Subtotal (Total Children Is Unduplicated) 56 355.000000 31522.8000 88.7966
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Total 419.500000 35998.7000 85.8133
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Number of Children (Unduplicated) With at Least One Service 77
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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 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 401 326.750000 28295.2000 28295.2000
115 92.750000 7703.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 516 419.500000 35998.7000 28295.2000