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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 2225 7112.250000 264475.5000 37.1859
Subtotal (Total Children Is Unduplicated) 2225 7112.250000 264475.5000 37.1859
-----------------------------------------------------------------------------------------------------------------------
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 3 5.500000 412.5000 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 2 3.500000 262.5000 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 125 220.000000 16500.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 145 275.000000 20625.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 45 76.500000 5737.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 77 143.500000 10723.5000 74.7282
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 40 75.000000 5625.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 29 55.500000 4162.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 130 240.000000 13320.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 161 304.500000 16899.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 66 112.000000 8400.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 36.000000 2700.0000 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) 431 1615.000000 109052.1350 67.5245
-----------------------------------------------------------------------------------------------------------------------
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 19433.750000 990241.4150 50.9547
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2421
-----------------------------------------------------------------------------------------------------------------------
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 49 42.250000 1796.1000 0.0000
U 0 0.000000 0.0000 0.0000
B 8558 7520.250000 321693.0500 0.0000
P 4 13.250000 935.5200 137.5000
D 115 146.000000 8613.5600 0.0000
S 387 248.750000 9760.1200 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3797 10872.000000 622552.9650 0.0000
Other 630 591.250000 24890.1000 0.0000
---------------------------------------------------------
Total 13540 19433.750000 990241.4150 137.5000