CMS/EIP Fiscal Report Center: 02
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 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 7.2000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.9200 28.9200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 13.8100 13.8100
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.8100 115.8100
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 28.000000 2100.0000 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 11 21.000000 1575.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 4.000000 211.7200 52.9300
Subtotal (Total Children Is Unduplicated) 32 76.500000 5218.6100 68.2171
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 4.000000 4716.6500 1179.1625
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 6.000000 300.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 25 143.500000 10197.9600 71.0659
OCCT-97530GT-OT SESSION BY LICENSED OT 1 8.750000 629.6500 71.9600
PHY-97110-PT SESSION BY LICENSED PT 16 72.250000 4897.9400 67.7916
PHY-97110GT-PT SESSION BY LICENSED PT 1 2.250000 161.9100 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 192.000000 13357.2600 69.5691
Subtotal (Total Children Is Unduplicated) 58 428.750000 34261.3700 79.9099
-----------------------------------------------------------------------------------------------------------------------
Total 505.250000 39479.9800 78.1395
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 80
-----------------------------------------------------------------------------------------------------------------------
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 520 440.000000 35219.8800 35121.5700
84 63.250000 4149.1000 0.0000
Other 1 2.000000 111.0000 0.0000
---------------------------------------------------------
Total 605 505.250000 39479.9800 35121.5700