CMS/EIP Fiscal Report Center: 57
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
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.500000 18.6000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 2.358872 87.7500 37.2000
Subtotal (Total Children Is Unduplicated) 2 2.858872 106.3500 37.2000
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Screening, Eval, and Assessment,Class #02
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 3 3.000000 41.4000 13.8000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 5 5.000000 101.5400 20.3080
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.000000 87.9800 14.6633
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 24.1900 8.0633
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 6.000000 173.3200 28.8867
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 13.8100 13.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 4 4.000000 84.0100 21.0025
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 15 27.000000 1984.9300 73.5159
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 18 34.500000 1914.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 225 419.500000 30830.6700 73.4938
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 50 91.500000 6558.6500 71.6792
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 59 106.500000 7589.5600 71.2635
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 300 567.000000 30849.0000 54.4074
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 36.000000 2650.0000 73.6111
OCTF-97168-OT RE-EVAL EST PLAN CARE 16 15.361604 780.4300 50.8039
OCTH-97165-OT EVAL LOW COMPLEXITY 6 5.404396 276.7600 51.2102
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 41 39.382033 2021.3900 51.3277
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 0.000000 0.0000 0.0000
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 55 61.167090 3141.7200 51.3629
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 27 29.000001 1487.2900 51.2859
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 154.2300 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.8600 44.8600
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 28.133574 1510.8500 53.7027
Subtotal (Total Children Is Unduplicated) 428 1511.448698 93533.3100 61.8832
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 104.000000 5200.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 5.000000 50.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 67 739.025359 52993.1894 71.7069
OCCT-97530GT-OT SESSION BY LICENSED OT 1 5.000000 357.2000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 18 125.838544 7248.1000 57.5984
PHY-97110-PT SESSION BY LICENSED PT 12 76.303782 5480.9400 71.8305
PHY-97110GT-PT SESSION BY LICENSED PT 2 4.500000 323.8200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 6 56.000005 3223.3600 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 99 1462.672518 105180.5200 71.9098
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 7 79.500000 5718.7400 71.9338
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 10 50.567613 2908.1800 57.5107
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 4 7.952431 458.0600 57.6000
Subtotal (Total Children Is Unduplicated) 186 2716.360252 189142.1094 69.6307
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Total 4230.667822 282781.7694 66.8409
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Number of Children (Unduplicated) With at Least One Service 491
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Center 57
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 300 361.614047 24927.2800 29030.3800
D 116 216.500000 14355.7500 0.0000
S 7 14.351585 854.8600 854.8600
H 28 28.000000 526.2500 526.2500
T 848 1817.035102 126620.9994 126621.0000
839 1787.167088 115093.5900 52427.0800
Other 5 6.000000 403.0400 403.0400
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Total 2143 4230.667822 282781.7694 209862.6100