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: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 4 4.000000 78.0400 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 4.000000 58.7200 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 35.2400 8.8100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.000000 115.6800 28.9200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 4 4.000000 84.1600 21.0400
EXIT-EXIT-COS Exit 1 0.750000 37.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 13.500000 1012.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 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 4 9.500000 712.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 131 289.000000 21750.0000 75.2595
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 62 127.000000 9525.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 30 58.500000 4387.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 35 73.000000 5475.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 29 49.000000 3675.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 8 15.000000 1125.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 112 231.500000 12848.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 49 102.000000 5709.7500 55.9779
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 79.000000 5850.0000 74.0506
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 18.500000 1387.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 8 8.000000 411.2800 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 7 8.000000 359.8700 44.9838
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 4.000000 143.9200 35.9800
SPCH-92521-EVAL OF SPEECH FLUENCY 19 19.000000 976.7900 51.4100
SPCH-92521GT-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 8.000000 359.8700 44.9838
Subtotal (Total Children Is Unduplicated) 284 1146.250000 76907.8700 67.0952
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 175 878.250000 60442.6200 68.8217
OCCT-97530GT-OT SESSION BY LICENSED OT 4 4.500000 323.8200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 27 91.500000 5179.4500 56.6060
PHY-97110-PT SESSION BY LICENSED PT 185 822.000000 57533.3900 69.9920
PHY-97110GT-PT SESSION BY LICENSED PT 3 5.000000 359.8000 71.9600
PHY-97110HM-PT SESSION BY PT ASST 8 42.000000 2417.5200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 257 1388.750000 96160.9200 69.2428
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 11 35.000000 2518.6000 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 5.500000 316.8000 57.6000
Subtotal (Total Children Is Unduplicated) 434 3272.500000 225252.9200 68.8321
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Total 4418.750000 302160.7900 68.3815
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Number of Children (Unduplicated) With at Least One Service 665
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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 1265 2206.750000 149925.9600 149925.9600
D 2 2.500000 179.9000 0.0000
S 6 5.500000 128.9400 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1375 2204.000000 151925.9900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2648 4418.750000 302160.7900 149925.9600