CMS/EIP Fiscal Report Center: 06
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 7.9200 7.9200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 31.8100 31.8100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 15.1900 15.1900
AUDE-V5010-ASSESSMENT FOR HEARING AID 4 4.000000 118.4400 29.6100
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.8100 115.8100
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
Subtotal (Total Children Is Unduplicated) 6 12.000000 550.1700 45.8475
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EI Services,Class #03
AUDE-V5160-DISPENSING FEE BINAURAL 2 2.000000 461.2400 230.6200
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 0.500000 25.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 10.000000 500.0000 50.0000
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 459.2200 459.2200
SENS-V5264-EARMOLD 5 9.000000 181.3000 20.1444
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 12 23.500000 1698.7200 72.2860
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Total 35.500000 2248.8900 63.3490
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Number of Children (Unduplicated) With at Least One Service 14
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Center 06
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
31 35.500000 2248.8900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 31 35.500000 2248.8900 0.0000