CMS/EIP Fiscal Report Center: 54
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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 14 48.000000 1784.4500 37.1760
Subtotal (Total Children Is Unduplicated) 14 48.000000 1784.4500 37.1760
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Screening, Eval, and Assessment,Class #02
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.000000 56.1000 56.1000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.5100 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 8 8.000000 117.3400 14.6675
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 22.0700 22.0700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 10 10.000000 79.7700 7.9770
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 8 8.000000 230.7600 28.8450
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 45.0800 45.0800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 41.2300 13.7433
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 21.0400 21.0400
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 2.000000 90.6400 45.3200
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 8 15.000000 1125.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 11.000000 610.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 18.500000 1387.2500 74.9865
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 29 53.500000 4162.5000 77.8037
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 29.500000 2212.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 71 137.500000 10312.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 35.500000 2662.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 33 62.000000 4650.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 29 53.500000 2969.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 86 160.500000 8907.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 44.000000 3300.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 35 70.000000 5250.0000 75.0000
Subtotal (Total Children Is Unduplicated) 220 751.000000 49954.7900 66.5177
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 28 73.000000 9093.0700 124.5626
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1 1.000000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 3 3.000000 112.5000 37.5000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 140 1056.250000 52812.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 131 598.750000 29937.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 50 412.840000 30519.4700 73.9257
OCCT-97530GT-OT SESSION BY LICENSED OT 36 142.620000 10720.4900 75.1682
OCCT-97530TL-OT SESSION BY LICENSED OT 3 5.000000 359.8000 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 2 3.000000 214.8400 71.6133
PHY-97110-PT SESSION BY LICENSED PT 50 470.460000 35339.0800 75.1160
PHY-97110GT-PT SESSION BY LICENSED PT 24 52.750000 3787.1800 71.7949
SENS-V5264-EARMOLD 4 9.000000 163.1700 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 64 554.180000 39871.9700 71.9477
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 29 61.250000 4400.0100 71.8369
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 143.9200 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 4.000000 287.8400 71.9600
Subtotal (Total Children Is Unduplicated) 341 3449.100000 217763.3400 63.1363
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Total 4248.100000 269502.5800 63.4407
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Number of Children (Unduplicated) With at Least One Service 404
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Center 54
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 75 64.520000 8117.6700 8054.2900
D 566 597.330000 37382.3200 0.0000
S 0 0.000000 0.0000 0.0000
H 453 501.750000 36064.9300 0.0000
T 1312 1383.480000 78010.8600 77882.1300
1539 1691.270000 109239.2500 0.0000
Other 10 9.750000 687.5500 0.0000
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Total 3955 4248.100000 269502.5800 85936.4200