CMS/EIP Fiscal Report Center: 10
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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 32 32.000000 624.3200 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 32 32.000000 469.7600 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 33 33.000000 237.6000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 32 32.000000 925.4400 28.9200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 33 33.000000 694.3200 21.0400
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 9.000000 675.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 10.500000 787.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.500000 187.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.500000 337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 13.000000 721.5000 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 62 129.500000 9750.0000 75.2896
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 104 204.000000 15300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 35.000000 2625.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 40 79.000000 5925.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 22 37.500000 2812.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 20 36.000000 2700.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 59 113.000000 6271.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 124 240.500000 13347.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 80.000000 6000.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 21.000000 1575.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 8 8.000000 365.5600 45.6950
OCTH-97166-OT EVAL MODERATE COMPLEXITY 9 9.000000 462.6900 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 6 7.000000 308.4600 44.0657
SPCH-92521-EVAL OF SPEECH FLUENCY 23 22.000000 1084.9250 49.3148
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 205.6400 51.4100
Subtotal (Total Children Is Unduplicated) 316 1246.500000 75692.7850 60.7243
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 3352.0400 1676.0200
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 5.000000 250.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 152 672.500000 46684.6400 69.4195
OCCT-97530GT-OT SESSION BY LICENSED OT 12 41.250000 2968.3500 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 24 137.750000 7876.8000 57.1819
OCCT-97530HMGT-OT SESSION BY OT ASST 2 6.750000 388.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 163 656.750000 45538.0000 69.3384
PHY-97110GT-PT SESSION BY LICENSED PT 7 22.500000 1619.1000 71.9600
PHY-97110HM-PT SESSION BY PT ASST 1 1.750000 86.4000 49.3714
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 248 1265.000000 87110.1000 68.8617
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 15 59.000000 4245.6400 71.9600
Subtotal (Total Children Is Unduplicated) 419 2870.250000 200119.8700 69.7221
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Total 4116.750000 275812.6550 66.9977
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Number of Children (Unduplicated) With at Least One Service 664
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Center 10
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 1383 2129.000000 145692.7700 145692.7700
D 4 3.500000 251.8600 0.0000
S 37 39.000000 1080.0600 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1150 1945.250000 128787.9650 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2574 4116.750000 275812.6550 145692.7700