CMS/EIP Fiscal Report Center: 54
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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 7 37.000000 1375.6000 37.1784
Subtotal (Total Children Is Unduplicated) 7 37.000000 1375.6000 37.1784
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 2.000000 396.8000 198.4000
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.000000 56.1000 56.1000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.5100 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.000000 44.0400 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 21.6000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.9200 28.9200
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 45.0800 45.0800
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.3200 45.3200
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 15.500000 1162.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 18 35.000000 2625.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 11.500000 862.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 8 15.500000 1162.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 18 33.500000 1859.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 12.000000 900.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 29.500000 2212.5000 75.0000
Subtotal (Total Children Is Unduplicated) 66 205.000000 14062.8700 68.5994
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 17.000000 1223.3200 71.9600
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 5 4.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 61 205.000000 10250.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 49 118.000000 5900.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 30 117.250000 8437.3100 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 17 23.000000 1655.0800 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 3 2.500000 179.9000 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 29 110.000000 7915.6000 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 9 16.000000 1151.3600 71.9600
SENS-V5264-EARMOLD 1 2.000000 36.2600 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 26 117.000000 8419.3200 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 12 17.250000 1241.3100 71.9600
Subtotal (Total Children Is Unduplicated) 174 750.250000 46481.4200 61.9546
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Total 992.250000 61919.8900 62.4035
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Number of Children (Unduplicated) With at Least One Service 220
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Center 54
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 1 0.500000 35.9800 35.9800
D 64 68.000000 3641.1700 0.0000
S 0 0.000000 0.0000 0.0000
H 23 22.500000 1619.1000 0.0000
T 112 119.010000 6569.7000 6569.7000
709 781.990000 50044.6900 0.0000
Other 1 0.250000 9.2500 0.0000
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Total 910 992.250000 61919.8900 6605.6800