CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 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 2187 6925.250000 257777.4000 37.2228
Subtotal (Total Children Is Unduplicated) 2187 6925.250000 257777.4000 37.2228
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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 8.8100 8.8100
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 7 13.000000 975.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 225.0000 56.2500
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 9.500000 527.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 259 476.000000 35737.5000 75.0788
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 76 141.500000 10612.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 55 93.500000 7050.0000 75.4011
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 35 60.000000 4500.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 68 103.500000 7950.0000 76.8116
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 12.500000 937.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 193 358.000000 19785.7500 55.2675
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 76 141.000000 7825.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 79 131.500000 9862.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 5 5.000000 257.0500 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 10 10.000000 514.1000 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 7 7.000000 359.8700 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 18 18.000000 925.3800 51.4100
SPCH-92521GT-EVAL OF SPEECH FLUENCY 3 3.000000 154.2300 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 154.2300 51.4100
Subtotal (Total Children Is Unduplicated) 445 1621.000000 110328.0700 68.0617
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 4.000000 100.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 694 4879.750000 244037.5000 50.0102
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 354 1844.250000 92212.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 186 836.250000 60176.5500 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 8 20.000000 1439.2000 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 53 218.500000 12608.0000 57.7025
OCCT-97530HMGT-OT SESSION BY OT ASST 2 3.000000 172.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 226 793.750000 57118.2500 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 5 7.000000 503.7200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 16 74.000000 4259.4400 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 5 18.500000 1064.8600 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 287 1507.250000 108461.7100 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 16 39.750000 2860.4100 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 11.500000 662.4000 57.6000
Subtotal (Total Children Is Unduplicated) 1264 10257.50000 585677.3400 57.0975
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Total 18803.750000 953782.8100 50.7230
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Number of Children (Unduplicated) With at Least One Service 2411
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Center 10
Flag Claims Units Chgs Paid
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R 47 32.750000 1218.3000 0.0000
U 0 0.000000 0.0000 0.0000
B 8885 8002.000000 346828.6500 0.0000
P 17 25.500000 1528.9000 132.0000
D 15 11.750000 449.9000 0.0000
S 18 30.750000 1754.0100 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5153 10407.750000 590981.9500 0.0000
Other 404 293.250000 11021.1000 0.0000
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Total 14539 18803.750000 953782.8100 132.0000