CMS/EIP Fiscal Report Center: 02
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
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 2 2.000000 231.6200 115.8100
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 5.500000 412.5000 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 33 62.500000 4687.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 14.000000 1050.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 16.000000 1200.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 37.1500 37.1500
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 154.2300 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 3 3.000000 154.2300 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 5 7.000000 248.6400 35.5200
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 4 4.000000 174.3300 43.5825
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 113.9800 37.9933
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 19 19.000000 976.0700 51.3721
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 3 17.000000 854.8500 50.2853
Subtotal (Total Children Is Unduplicated) 83 177.000000 11252.5500 63.5737
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 8 18.000000 28917.9200 1606.5511
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 14 56.000000 2800.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 47 560.500000 38518.9200 68.7224
OCCT-97530GT-OT SESSION BY LICENSED OT 5 57.000000 4099.6400 71.9235
PHY-97110-PT SESSION BY LICENSED PT 34 367.250000 22142.1200 60.2917
PHY-97110GT-PT SESSION BY LICENSED PT 4 22.250000 1316.0200 59.1470
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 459.2200 459.2200
SENS-V5264-EARMOLD 2 3.000000 54.3900 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 79 765.750000 52856.2100 69.0254
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 18.500000 1325.6700 71.6578
Subtotal (Total Children Is Unduplicated) 130 1869.250000 152490.1100 81.5782
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Total 2046.250000 163742.6600 80.0208
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Number of Children (Unduplicated) With at Least One Service 161
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Center 02
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 3 3.000000 99.4600 -116.4200
H 0 0.000000 0.0000 0.0000
T 2489 1931.500000 155714.4900 156106.3660
145 109.750000 7817.7100 0.0000
Other 1 2.000000 111.0000 0.0000
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Total 2638 2046.250000 163742.6600 155989.9460