CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 Page: 1
List order: No List
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 2151 6796.000000 252711.1000 37.1853
Subtotal (Total Children Is Unduplicated) 2151 6796.000000 252711.1000 37.1853
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
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-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 7.2000 7.2000
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-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 4 9.000000 675.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 113 199.000000 14925.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 120 230.000000 17250.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 37 63.000000 4725.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 61 117.000000 8736.0000 74.6667
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 39 73.000000 5475.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 27 52.500000 3937.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 113 210.500000 11682.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 138 264.500000 14679.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 63 106.000000 7950.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 26.000000 1950.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 8 8.000000 411.2800 51.4100
OCTH-97165GT-OT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 8 8.000000 411.2800 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 11 10.500000 539.8050 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 257.0500 51.4100
Subtotal (Total Children Is Unduplicated) 378 1414.500000 95369.8850 67.4230
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 501 3978.250000 198862.5000 49.9874
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 454 2918.000000 145900.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 194 891.000000 64116.3600 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 25 56.250000 4047.7500 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 48 160.750000 9259.2000 57.6000
OCCT-97530HMGT-OT SESSION BY OT ASST 2 4.500000 259.2000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 253 989.500000 71174.6600 71.9299
PHY-97110GT-PT SESSION BY LICENSED PT 4 7.000000 503.7200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 3 4.500000 259.0200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 288 1596.750000 115185.6300 72.1375
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 31 96.500000 6944.1400 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 3.500000 201.6000 57.6000
Subtotal (Total Children Is Unduplicated) 1254 10706.50000 616713.7800 57.6018
-----------------------------------------------------------------------------------------------------------------------
Total 18917.000000 964794.7650 51.0015
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2342
-----------------------------------------------------------------------------------------------------------------------
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 49 42.250000 1796.1000 0.0000
U 0 0.000000 0.0000 0.0000
B 8174 7033.750000 297691.8000 0.0000
P 4 13.250000 935.5200 137.5000
D 107 133.500000 7940.6600 0.0000
S 383 241.500000 9490.4200 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3795 10868.000000 622291.9650 0.0000
Other 625 584.750000 24648.3000 0.0000
---------------------------------------------------------
Total 13137 18917.000000 964794.7650 137.5000