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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 15 57.000000 2119.2500 37.1798
Subtotal (Total Children Is Unduplicated) 15 57.000000 2119.2500 37.1798
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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 6 11.500000 862.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 13 23.500000 1762.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 8.000000 600.0000 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 6 10.500000 582.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 15.000000 832.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 22.000000 1649.7500 74.9886
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 39 70.500000 5437.5000 77.1277
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 21 36.000000 2700.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 102 196.000000 14700.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 24 42.000000 3150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 56 104.000000 7800.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 46 85.500000 4745.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 126 232.000000 12876.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 61.500000 4612.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 52 105.000000 7875.0000 75.0000
Subtotal (Total Children Is Unduplicated) 320 1068.000000 71584.7900 67.0270
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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 4574.100000 291467.3800 63.7213
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Number of Children (Unduplicated) With at Least One Service 504
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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 582 620.330000 38689.1200 0.0000
S 0 0.000000 0.0000 0.0000
H 471 533.750000 38464.9300 0.0000
T 1359 1468.480000 83137.8600 83009.1300
1641 1877.270000 122370.2500 0.0000
Other 10 9.750000 687.5500 0.0000
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Total 4138 4574.100000 291467.3800 91063.4200