CMS/EIP Fiscal Report Center: 07
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 Page: 1
List order: No List
Payclass Filters:TPIN
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 2 1.000000 37.2000 37.2000
Subtotal (Total Children Is Unduplicated) 2 1.000000 37.2000 37.2000
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 5.000000 73.4000 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 8.000000 57.6000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.000000 144.6000 28.9200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 41.4300 13.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 21.0400 21.0400
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 28.0000 28.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 42.000000 3150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 32.000000 2400.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 11.049400 828.7000 74.9995
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 5 5.000000 257.0500 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 154.2300 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 4.000000 205.6400 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 12 12.000000 616.9200 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 154.2300 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.8600 44.8600
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 12.000000 584.3100 48.6925
Subtotal (Total Children Is Unduplicated) 93 187.049400 11569.0600 61.8503
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 21 72.000000 3600.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 4 11.500000 575.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 28 103.750000 7465.8500 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 2 2.500000 179.9000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 28 103.000000 7411.8800 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.750000 125.9300 71.9600
SENS-V5264-EARMOLD 1 1.000000 18.1300 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 83 356.500000 25601.3600 71.8131
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 13.000000 935.4800 71.9600
Subtotal (Total Children Is Unduplicated) 146 665.000000 45913.5300 69.0429
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Total 853.049400 57519.7900 67.4284
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Number of Children (Unduplicated) With at Least One Service 218
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Center 07
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 393 769.049400 51304.5900 51304.5900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 8.000000 600.0000 0.0000
T 0 0.000000 0.0000 0.0000
36 66.000000 4865.2000 0.0000
Other 5 10.000000 750.0000 0.0000
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Total 438 853.049400 57519.7900 51304.5900